The most obvious answer is don’t engage in intentional fraudulent schemes involving claim submissions to Medicare or private insurance programs seeking more compensation than you would otherwise be entitled. Keep in mind that, despite the fearsome issue of honest billing errors leading to criminal investigations, most criminal investigations stem from fraudulent conduct that is reported by an employee, third party, or an insurance program, itself. Health care fraud is a national problem that passes loss onto consumers in the form of higher premiums and poorer economic output. Bear in mind that facts used to illustrate previous points in earlier articles are fictional and not to be confused with actual criminal cases or intended to suggest the guilt or innocence of any actual defendant. United States prosecutors and investigators are honorable and discharge their responsibilities ably and well. Qualified defense attorneys perform equally well, but the rubber meets the road with the age old adage, “If you can’t do the time, don’t do the crime.”
And for those sailing with an ethical compass, but with a sloppy, poorly trained crew, don’t despair. Four words will help get you back in command and set your ship aright: Health care compliance audit. There’s nothing magical to this. No short cuts and no sweeping stuff under the rug. If you have a dirty kitchen, you either clean it up or it stays dirty. The answer to cleaning up sloppy billing procedures is no different. Just do it.
Where do you find these amazing problem solvers? From referrals from others; from trade journals and the Internet. But a word of caution: Check the resume. An unqualified person is going to do this job poorly and leave you with false security. Health care laws are complex. Folks make a living out of figuring them out. Proper health care billing, in all respects, requires a breadth of knowledge of various matters, from CMS regulations governing Medicare, to criminal codes, to private insurance program policies, to CPT terminology and industry interpretations, to common understandings of ordinary and customary billing practices.
After your compliance audit is completed, conduct an interview with the auditor; find out where your danger spots are and make corrections as advised. Then, schedule a tune up on a periodic basis to make sure time, and the laws are not passing you by. Be good to your practice and it will be good to you.
The other thing you can do is to take an inventory of your crew. If you started out from Bermuda, charted a course to the Bahamas, and ended up in Iceland, chances are that, no matter how much you know about sailing, something’s going awry when you’re not in the cockpit. If it’s not the boat itself, then, well, the source of the problem should be pretty obvious. If you have unqualified employees in positions of responsibility, requiring them to code medical procedures, fill out HFCA claim forms, interpret your handwriting on medical records, even type in input for your computer billing program, then you have a problem akin to a gambling addiction without any upside chance of ever hitting it big. You may as well spend your time painting placards that say,”I am innocent!” and march in circles around the nearest courthouse. In fact, there comes a point when recklessness creeps awfully close to deserving what one gets. Don’t be reckless. Don’t try to save expenses by hiring undereducated, under qualified wonder kids, expecting them to figure everything out for pennies to the dollar. If you have unqualified folks doing your billing, let them go. If you don’t have any, just say, “No.”
Larry Economos, a civil and criminal defense attorney whose practice focuses on federal health care fraud defense, is a managing partner with Mills & Economos, LLP. Mr. Economos can be contacted via his website address, www.leconomoslaw.com, or by telephone at 800-456-0460, 704-375-9913, or 252-752-6161.