Responding to Allegations of Fraudulent Healthcare Credentialing


Responding to Allegations of Fraudulent Healthcare Credentialing

Allegations of fraudulent credentialing in healthcare can have serious consequences for providers. Credentialing refers to the process of verifying the qualifications and licenses of healthcare professionals to ensure they meet certain standards of care. If allegations surface that a provider falsified information or misrepresented their credentials, it can lead to audits, investigations, penalties, and even criminal charges. So how should a healthcare organization or individual provider respond if faced with such allegations?

Understand the Allegations

The first step is to fully understand the specifics of the allegations. Who is making the claims and what evidence do they cite, if any? Common allegations include lying about or exaggerating education, training, certification status, malpractice history, or affiliations with hospitals or health plans. Make sure you know exactly what aspects of credentialing are being questioned before determining how to respond.

Conduct an Internal Investigation

Once the parameters of the allegations are clear, an internal investigation should commence. Appoint an independent auditor or compliance team to thoroughly review the credentialing files, applications, and any other relevant documentation of the providers in question. Compare the paperwork to the allegations to identify any actual discrepancies, rather than just taking the claims at face value. Document the findings of the investigation.

Assess the Severity

The severity of fraudulent credentialing can range from an unintentional paperwork oversight to outright fabrication of credentials. Intent and the type of misrepresentation matters when it comes to potential penalties. If the internal audit reveals only minor issues, like a clerical error or outdated document, that merits a far different response than systemic, intentional falsification of credentials. Assess the scope and intent behind any credentialing discrepancies uncovered.

Consider Voluntary Self-Disclosure

If the audit does reveal significant credentialing issues in violation of regulations and laws, voluntarily self-disclosing to the authorities may be the best path forward. This shows that the organization takes the allegations seriously and is willing to take responsibility. Self-disclosure can result in reduced penalties and even avoidance of criminal charges in some cases. Consult with knowledgeable legal counsel to decide if voluntary disclosure makes sense.

Cooperate Fully with Any External Investigation

If allegations of fraudulent credentialing prompt an investigation by Medicare, Medicaid, private health plans, or other authorities, it’s essential to cooperate fully. Supply all requested files and documentation in a timely manner. Make staff available for interviews. Answer questions honestly. Obstruction or evasion will only cast further suspicion and likely worsen outcomes. That said, ensure legal counsel is present for any interviews to safeguard the legal rights of the organization and its providers.

Appeal Any Adverse Actions

In cases of severe or systemic credentialing fraud, authorities may impose fines, payment suspensions, exclusion from federal healthcare programs, or other adverse actions. These actions can deeply impact an organization or provider’s ability to operate and serve patients. If faced with such actions, be aware that appeals options exist through administrative law courts or even federal district courts in some cases. An experienced healthcare attorney can advise on the viability of appeals to fight any unjust adverse actions.

Assess Potential Liability

Beyond direct government penalties and sanctions, fraudulent credentialing can also prompt legal action from other parties that incur damages as a result. Patients may file medical malpractice lawsuits if they feel they received substandard care from a provider who lied about their qualifications. Private health plans may seek to recoup payments made to that provider. Evaluate all potential financial and legal liabilities with counsel based on the specifics of the credentialing breakdown.

In summary, allegations of fraudulent credentialing must be taken very seriously by healthcare providers and organizations. Conduct a prompt yet thorough internal investigation to determine the validity of the claims. Assess the severity of any actual credentialing discrepancies uncovered and take appropriate corrective and disclosure actions. Cooperate fully with any external audits or investigations. And be aware of potential financial, legal, and regulatory liabilities—working closely with knowledgeable counsel every step of the way. Acting swiftly while exercising due diligence offers the best chance to resolve the allegations with minimal damage or disruption