State and federal governments are working to crack down on the overpayments issued to medical facilities each year as they exceed a billion dollars annually. Medicaid and Medicare are government issued healthcare programs that fund the affordability of healthcare for those with low-incomes, the disabled, and the elderly. These programs are designed to offer support to those who require medical attention, but they’re costing taxpayers and the government substantially each year. To eliminate the vast overpayments issued annually, insurance companies and the government solicit the help of healthcare auditors and investigators.
Any healthcare facility can be audited or investigation. Some are chosen at random, and others are chosen for an audit based on red flags and potential overpayment that’s noticed by the payer. The process begins with an audit, and only results in an investigation when an office is suspected of committed fraud. If your office is being audited, it’s not a reason to worry. It’s still a good idea to call a healthcare auditor and investigation attorney who specializes in this type of medical law.
The Audit Process
Unless chosen randomly, a medical facility is not audited for overpayment issues unless there is a red flag appearing in one or more locations throughout the payment process.
– Many patients are being charged for the same procedure. This is a massive red flag for auditors as it means one doctor’s office is charging multiple patients for the same type of care. Since most people have different health needs, it’s sometimes a red flag when dozens of patients seem to suffer from the same issues requiring the same expensive testing or procedures. Of course, this happens often at offices with a specialty focus, or when there is an outbreak of a specific illness or disease in a specific city.
– Duplicate bills are paid for the same patient for the same appointment. This occurs from time to time due to administrative error. If two people in the same office submit the same paperwork to insurance companies by mistake, duplicate bills are issued. It’s not fraudulent to make mistakes, and most of these issues are very easily handled.
– Many patients are being given multiple tests and procedures at every appointment. When you have one patient who comes into the office for one issue and ends up having multiple tests done, it’s not an issue. When dozens of patients come in for a simple cold and end up leaving with thousands of dollars in procedures noted, it’s suspicious.
Most overpayments are mistakes, and they’re easily corrected. Medical facilities needn’t worry they are in trouble with the federal government because a clerical error resulted in an incorrect bill. However, some audits show a significant presence of mistakes, and it makes an investigation necessary.
When a doctor’s office is unable to prove their overpayment mistakes were just mistakes or there are so many mistakes it looks suspicious, an investigation is opened by the federal government. This requires the office to comply with the requests of the government, and it usually results in bad news for the physician in charge. If found guilty of fraud, the physician faces the following punishments.
– Fines – Most fines are not to exceed $5,000 per count.
– Restitution – If a doctor is guilty of stealing money by falsifying records, incorrectly charging patients, or overcharging insurance companies, they’re required to pay back every penny they took.
– Prison Time – Fraud is a federal criminal offense, and each count is worth up to five years in prison.
– Loss of a Medical License – When a doctor is accused of fraud and tried in a court of law, they obtain a criminal record. No doctor with a criminal record is able to continue practicing, so their license is revoked permanently with no chance of reinstatement.
It’s always a good idea to turn to an attorney with ample legal experience in this type of case. Even if an attorney can’t turn a guilty client into an innocent one, they can work to have charges reduced following settlement hearings and other forms of discipline. Attorneys can also help medical facilities avoid further chance of auditors showing up by helping with billing laws and legal expertise.