Question

what are some strategies in health care to prevent financial fraud?

Answer 1

Healthcare fraud

Healthcare fraud and abuse cases cost the industry billions of dollars a year. Without processes in place to detect and prevent fraudulent activities, healthcare providers could face an investigation that may cost them their reputation and revenue.

However, developing appropriate healthcare fraud and abuse prevention policies and compliance programs may be difficult for provider organizations.Providers face multiple healthcare fraud and abuse laws at the local, state, and federal levels. Complying with the myriad of regulations can be difficult for providers who already focus on a range of priorities, including care delivery, payer compliance, medical billing, and revenue cycle management. As value-based purchasing takes hold of the healthcare industry, providers are also seeing claims reimbursement rates drop in favor of incentive payments.

Efforts to maximize revenue may push some providers to engage in healthcare fraud and abuse activities without intending to, such failing to correct a billing clerk who assumes a provider performed specific services, billing for medications that patient never picked up, and coordinating with other provider organizations under value-based agreements.While providers may or may not intend to commit healthcare fraud and abuse crimes, the federal government is as strict as ever with cracking down on fraud schemes.

HHS recently reiterated its commitment to preventing healthcare fraud and abuse. The federal department stated last year that CMS implemented a proactive approach to fraud protection, eliminating its previous pay-and-chase method.The federal department now uses predictive analytics to prevent false medical bills before providers receive payments. CMS also upped its efforts to screen providers properly for enrollment in federal healthcare programs.

Providers may find that Medicare and Medicaid officials are scrutinizing claim submissions more than ever to detect potential improper billing practices.To prevent an organization from participating in healthcare fraud and abuse activities, providers should understand key healthcare fraud laws, implement a compliance program, and improve medical billing and business operations processes.

Strategies in health care to prevent financial fraud

1. Stop the Government in Its Tracks

By the time you find out that you are under investigation, the U.S. Department of Justice (DOJ), Office of Inspector General (OIG), and various other federal agencies could already be coming after you full steam ahead. In order to slow down the investigation and prevent the government from filing charges before you have had a chance to tell your side of the story, you need to intervene in the investigation.

What does it mean to intervene? At Oberheiden, P.C., we use our extensive experience in federal health care fraud investigations to communicate effectively with the agents and prosecutors involved, determine the nature of the investigation (i.e., civil or criminal), and convince them that there is more than one story to be told. Once the government knows we are involved, the process slows down and you will have the opportunity to begin implementing a strategic defense.

2. Turn the Tables in Your Favor

In a typical health care fraud investigation, the federal agents and attorneys will have decades of combined experience in cases just like yours and several of them will likely hold senior positions within the DOJ or OIG. This puts you at a distinct disadvantage. But, by engaging a defense team comprised of nationally-renowned defense attorneys and former senior health care fraud prosecutors, you can put the experience factor on your side.

3. Call out Faulty Assumptions and Methods

Despite their vast experience in health care fraud investigations, agents and prosecutors with the DOJ, OIG, and other agencies make mistakes just like everyone else. In addition, in cases involving investigations triggered by MAC, RAC, and ZPIC audits, it is not at all uncommon for the auditor to have reached faulty conclusions based upon flawed auditing methodologies and assumptions.

4. Dig Deep into the Provisions of the Federal Health Care Laws That Protect You

While the False Claims Act, Anti-Kickback Statute, Stark Law, and the various other laws the DOJ and OIG use to target health care providers are extremely broad in scope, they are also subject to a variety of statutory and regulatory exceptions. For example, the False Claims Act requires clear evidence of “specific intent to violate the law or . . . a consciousness that what [you were] doing was wrong,” in order to trigger criminal culpability. Another example is the Anti-Kickback Statute’s prohibitions on “remuneration” are subject to a laundry list of safe harbors that protect all types of compensation-based relationships.

5. Know When Enough Is Enough

Although cooperating with the government’s investigation can benefit you to a degree, you also need to know when enough is enough. If you are overly cooperative and you end up supplying federal agents with incriminating information, your willingness to help is not going to save you from criminal prosecution.

Likewise, when federal agents knock at your door or when the OIG sends you a subpoena in the mail, you need to know when the federal government is overstepping its authority. While the DOJ, OIG, and other federal agencies have broad investigatory powers, there are Constitutional, statutory, and regulatory limits to how far they can go.

6. Leverage the Facts (Or Lack Thereof)

Sometimes, the best defense is a good offense. While the government has the burden of proving your guilt beyond a reasonable doubt, if you have evidence that you are innocent, proving your innocence could stop the government in its tracks. On the other hand, if the facts are simply too convoluted and the evidence to support charges just isn’t there, this too is something you can use to leverage a favorable outcome prior to charges being filed.

7. Keep It Civil

Finally, if the government has evidence against you and charges appear to be on the horizon, then you may need to shift your focus to keeping the charges civil in nature. The legal standards in civil and criminal cases differ in more ways than one. In addition to limiting your potential exposure, keeping your case civil may also improve your chances of negotiating a favorable settlement prior to trial.

Regardless of the circumstances involved, if you are facing a federal health care fraud investigation, the worst thing you can do is nothing at all. You need to protect yourself by all means necessary, and this starts with engaging experienced defense representation.