Warning Signs of a Potential Health Care Fraud Investigation

While some of the warning signs of a potential health care fraud investigation are obvious, others are not.  Consider the obvious ones to be flashing red lights signaling you to stop and make sure you can move in safety before starting again.  The less obvious warning signs are cautionary, yellow lights signaling you to slow down and proceed with care.  Both require attention. 

The obvious signs have one thing in common: The insurance company.  They are fourfold in increasing order of severity:

1.  A billed health insurance company notifies you of an internal audit indicating unusual billing errors;
2.  Representatives of a billed health insurance company ask that you submit billing records for their review;
3.  Representatives of a billed insurance company come to your office asking to review records; and
4.  A billed health insurance company demands that you pay back a significant amount of money for alleged improper billing. 

Signs 1 and 2 demand that you stop conducting business as usual and conduct your own internal audit of treatment records and submitted bills.  Have an attorney involved to make certain your audit remains private and privileged.  Discover your own errors and implement corrective measures.  Allow a qualified health care fraud defense attorney to represent you in all correspondence and dealings with the insurance company.

If you’ve handled signs 1 and 2 properly, signs 3 and 4 may never appear.  If they do, you have laid a foundation to establish your innocence due to billing errors rather than to intentional acts of fraud.  The less obvious warning signs are threefold:

1.  Word gets around that a disgruntled employee is threatening retaliation;
2.  An employee notifies you that insurance claims have been submitted with significant billing errors; and
3.  Either you or a partner keeps scanty treatment records, often not fully documenting all your services.

When any of these signs appear, implement an internal review of your billing practices.  Scrutinize some randomly selected submitted claims for billing errors, however small, and implement corrections for future submissions.  Begin proper treatment documentation.  If significant billing errors are found or suspected, consider yourself seeing a flashing red light and proceed to implement corrective measures, as outlined above, for obvious warning signs 1 and 2.

Final word of caution: Make certain that your attorney is qualified and experienced in health care fraud defense.  Regardless of their experience level in criminal defense, health care fraud is a specialized area that requires experience and knowledge in Health Care Financing Administration (HCFA) 1500 form billing, Medicare laws, state and federal criminal law, private insurance company adoption of billing regulations, contractual notice, Continuous Performance Tests (CPT) chiropractic coding, incidental billing practices, as well as customary health care billing practices.  Not many attorneys have this experience.  Ask about prior experience, including past contacts with qualified medical billing compliance officers.  Don’t be a lawyer’s guinea pig.

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.

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