The Department of Justice designated 12 federal prosecutors across the country as part of the Opioid Fraud and Abuse Detection Units. These Units are assigned to areas where the most opioid drug-related deaths have occurred: California, Nevada, Alabama, Central Florida, East Tennessee, West Virginia, North Carolina, Kentucky, Ohio, Pennsylvania, Michigan, and Maryland. Members of these Units also includes numerous federal, state, and local law enforcement and governing entities including the DEA, FBI, HHS, and other federal and state agencies (Medicaid Fraud Control Units, FDA, IRS, State Pharmacy Boards, etc.). These Units have a specific mandate to target physicians, pharmacists, and ancillary services (addiction treatment centers, etc.).
During my 30 years in healthcare consulting, I have seen several reform initiatives come and go.
In many cases, the initiatives have enhanced the ability of consumers to access insurance coverage and ultimately healthcare. In 1993, President Clinton proposed legislation that led to growth in Health Maintenance Organizations (HMOs) and also the HIPAA privacy standards which are still in place today. In the 2000s, President George Bush proposed changes to the Medicare program that led to the implementation of Medicare Part D coverage.
Fraud. It’s an ugly thing and it’s everywhere, the medical industry is no exception. When most people think about fraud, they think about white collar criminals stealing millions of dollars from big name companies, or the “dark web” where most of our social security numbers and credit card numbers are floating around just waiting for a buyer. The truth is most businesses will experience some type of fraud during their operation. It is so important for owners and business managers to be constantly vigilant to protect their practices.
As today’s healthcare drive pushes practices even further down the path of pay for performance versus the older models of pay for volume, administrators and executives throughout healthcare are researching and implementing ideas to provide an overall better experience for patients.
Physicians and other medical care professionals spend years studying, training and preparing themselves to provide best possible care to their patients. In many instances, these professionals spend the bulk of their attention and energy on treating their patients and meeting the day-to-day challenges that come with providing the best care possible. Unfortunately, practicing in today’s economic climate within a medical industry undergoing a vast transformation has forced many medical professionals to place equal value on business issues that effect their practice. Often times, the business of operating a medical practice is never discussed in medical school. Instead, many healthcare professionals are forced to learn fundamental business principles on the fly in private practice. With the emergence of electronic medical records and coding, many healthcare providers and practices are spending a substantial amount of time concentrating on the business of healthcare in addition to patient care. Of all the business issues that must now be prioritized by the medical industry, medical billing and managing account receivables can bear the most burden of all.
No matter the size of the business, a successful business must be paid promptly and in full. However, often a business, including a medical practice is dealing with numerous overdue accounts receivables. Such a financial position can be commonplace in today’s business environment. Although this financial condition is often perceived as “normal” or “accepted” business practice”, savvy business owners should collect promptly and protect their rights in resolving overdue receivables with the proper policy and procedures in place. Effective policy and procedures generally begin with utilizing a new patient form and/or the credit application.
An Oklahoma physician agreed on August 28, 2017 to pay the government $580,000 to resolve allegations that he violated the False Claims Act by submitting claims to the Medicare program for services he did not provide or supervise. According to the government, the physician allowed a company that employed him and in which he had an ownership interest to use his NPI numbers to bill Medicare for physical therapy evaluation and management services that he did not provide or supervise. The government further alleged that after he separated from the company and deactivated his NPIs associated with the company, he reactivated those NPIs so that the company could use them to bill Medicare for services he neither performed nor supervised.
It has now been two years since the implementation of ICD-10, everyone survived! While denials have been minimal, the goal of implementing ICD 10 to acquire more specificity and a complete picture of health has not been fully achieved. Physicians and managers have created a new set of shortcuts to assure payment of claims, relying on paper superbills or inappropriate conversions from ICD 9 to ICD 10.
In the last 10-15 years, the use of mid-level providers has increased to expand the base of patients in many practices. The Nurse Practitioner scope of practice is more flexible and there are specialty designations available to foster expertise in certain areas. The insurance companies have expanded the number of plans covering a mid-level provider’s services.
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