How to Identify Healthcare Fraud Risks

Smart healthcare CEOs are focused on compliance risks. But sometimes the loudest risks aren't the ones that pose the greatest threat. In conversations with healthcare leaders, I've noticed a pattern. Many put tremendous emphasis on HIPAA, which makes complete sense. When they think about compliance, they think about HIPAA. And when they think about HIPAA, they think about IT security. This focus is understandable. Data breaches are public and create immediate reputation concerns. But here's what the numbers actually tell us: the largest OCR fine for a data breach was around $12 million. Last year alone, the federal government recovered over $3 billion from False Claims Act violations and anti-kickback penalties. That's just overbilling or not billing correctly. Hundreds of millions of dollars are being paid back by individual healthcare entities for False Claims Act violations. CEOs get so wrapped up in HIPAA security that they don't realize their business foundation is billing and collecting. If you're 40-60% government payers, that's a huge chunk of your revenue at risk. I talk to healthcare leaders all the time who say they're fine because they have good people looking at coding and billing. When I ask about their audit process, they often tell me they don't do audits but trust their people because they're good. That's mistake number one. Compliance exists because people make mistakes and errors. You have to test your billing and fix mistakes within 60 days, or it becomes a False Claims Act violation with multiple penalties. Here's the reality: you can insure against data breaches with cyber insurance. There's no insurance for False Claims Act violations. Your compliance program is your insurance against these violations and penalties. The three areas that deserve equal attention: 1. Balancing HIPAA focus with billing compliance oversight 2. Protecting your core revenue stream through proactive Medicare and Medicaid billing audits 3. Building systematic compliance processes that support your good people Your compliance program should protect your biggest asset: your revenue stream. Always here as a resource, message me. -RRR

UCHealth has agreed to pay $23 million to resolve allegations of fraudulent billing for emergency department visits. The settlement addresses claims that UCHealth violated the False Claims Act by improperly coding Evaluation & Management services, leading to overpayments from Medicare and TRICARE. What to Look for in Emergency Room Fraud🚨 1. Upcoding – Your visit is billed at a higher severity level than necessary (e.g., Level 4 or 5 for a minor issue). 2. Unnecessary Tests & Procedures – Charges for CT scans, MRIs, or lab tests that were not ordered or needed. 3. Billing for Services Not Provided – You are charged for doctors, specialists, or treatments you never received. 4. Duplicate Billing – The same test, procedure, or service appears more than once on the bill. 5. Unbundling Charges – Separate charges for services that should be billed together at a lower cost. 6. Balance Billing Violations – Being billed more than your insurance allows, despite in-network coverage. 7. Phantom Fees – Charges for medications, IVs, or medical supplies that were never used. 8. Drive-By Doctoring – Extra charges for multiple doctors or specialists who did not meaningfully interact with you. 9. Medicare & Medicaid Fraud – Incorrect coding to inflate reimbursement from government programs. 10. Surprise Billing – Unexpected out-of-network charges when the hospital or ER was supposed to be in-network. How to Protect Yourself: ✔ Always request an itemized bill and review each charge. ✔ Cross-check with your medical records to verify services provided. ✔ Dispute incorrect or excessive charges with the billing department. ✔ Report suspected fraud to your insurance provider or state regulators. #ERFraud #MedicalBilling #HealthcareFraud #FalseClaimsAct #BillingTransparency #FraudWasteAbuse #PatientRights #HealthcareFraud #FalseClaimsAct #Medicare #TRICARE #Compliance #HealthcareLaw #GovernmentEnforcement #PatientCare #unbundling #upcoding https://lnkd.in/ecfpi3FN

With increased federal scrutiny on Medicare fraud, Chronic Care Management programs are under the microscope. One area we see subject to risk is the initial patient eligibility assessment. To meet CMS coverage requirements and support a defensible billing position, documentation at the outset must include: - Evidence of an "initiating visit" (billed separately) for new patients or patients who the billing practitioner hasn’t seen within the previous 1 year. - At least two chronic conditions, expected to last at least 12 months, and pose a significant risk of death, acute exacerbation, or functional decline. - Patient consent to receive CCM services, including acknowledgement of potential cost-sharing. By getting ahead of these compliance risks with solid documentation practices, providers can reduce their chances of being flagged by auditors, and be well-prepared to handle audits if they do come. #HealthcareCompliance #ChronicCareManagement #CCM #MedicareBilling #CMSCompliance #AuditReadiness

The prevalence of these cases should not come as a surprise to the #healthcarefraud and #siu community. The expansion of telehealth, while a very key component of health continuity, and access to care, will come with weaknesses that will surely need to continually be addressed and monitored. The number one area that creates this weakness is the ability of providers to submit claims up to 12 months from the date of service. The unscrupulous providers will submit their claims as quickly as possible to ensure that they are paid quickly, per prompt pay rules that exist. The ordering provider, who is usually paid a kickback for the order, will usually not have a claim to submit since the ordering provider never examined or otherwise interacted with the patient. This "run to the finish line" approach on claims submissions was very prevalent with mail order diabetic testing supplies, where it was the responsibility of the Medicare beneficiary to notify their supplier of a change in suppliers (as if that happened). By creating an environment where timely filing of claims is so long, it opens a door of fraudulent opportunity where data analytics are not going to be able to show the lack of patient-provider relationship until it is too late. #fwa #paymentintegrity #ahla #hcca