Medicare and Medicaid Compliance
Medicare and Medicaid billing is a staple for many licensed healthcare professionals, and those professionals can ensure it stays that way by establishing an effective compliance program. The attorneys at Norman Spencer Law Group have extensive experience in the legal healthcare field, with more than 10 years helping clients create and maintain strong Medicare and Medicaid compliance programs.
A compliance program is an absolute necessity to ensure your practice is providing comprehensive and compliant claims for all supplies or services rendered during the delivery of patient care.
Penalties for non-compliant claims can be serious. They can include civil and administrative enforcement as well as criminal prosecution for Medicare or Medicaid fraud. Sometimes penalties can include all of the above, with administrative and civil enforcement actions that exclude healthcare professionals from treating Medicare and Medicaid patients.
Compliance Program as Survival Tool
Stricter program regulations and lower reimbursements make a compliance program an integral survival tool for all healthcare practices. An effective compliance program not only demonstrates a practice’s genuine effort to comply with the rules and regulations, but it’s also designed to protect it. Compliance programs can help identify and prevent incorrect and fraudulent claims, avoid billing mistakes and decrease the possibility of investigation and audit.
While the Office of Inspector General (OIG) does acknowledge that smaller practices may lack sufficient resources to implement extravagant compliance programs, it still expects them to adhere to regulations. Such practices still need to proactively address compliance in a way that ensures federal and state laws are followed.
Compliance Program Basics
Medicare and Medicaid compliance programs don’t have to be perfect, but they must be effective. Every healthcare practice that establishes and maintains a compliance program may also be given the benefit of reduced culpability in the event of a fraudulent claim, provided the practice can demonstrate the effectiveness of its program.
The lawyers at Norman Spencer Law Group have helped numerous clients establish compliance programs designed to pinpoint and correct claim weaknesses before they’re discovered by Medicare or Medicaid.
Help with Medicare and Medicaid Compliance
When helping clients with compliance programs, the first issue we often tackle is claims coding and billing. The OIG has identified claims coding and billing as the top risk area when it comes to Medicare and Medicaid claims.
Our compliance lawyers can help licensed healthcare professionals by addressing billing issues that could lead to problems. These include unstated procedures, missing charges, non-compliant or inaccurate charges, or issues associated with National Correct Coding Initiatives (NCCI).
The NCCI is a Medicare and Medicaid program established to prevent incorrect payment of procedures that should have never been submitted in the first place. The program has two categories that cover all healthcare practitioners and facilities.
It can be difficult to satisfy the full scope of Medicare and Medicaid coding requirements and documentation needed to receive the proper payment. Having a compliance program in place to identify and correct issues can make the process much easier.
It can also help licensed healthcare professionals avoid audits and investigations that can result in a demand for repayment for overcharges. Even for smaller practices, repayment amounts can easily reach or exceed hundreds of thousands of dollars. That’s in addition to any fines and potential civil and criminal penalties.
Compliance Violations and Penalties
The healthcare attorneys at Norman Spencer Law Group helps to ensure healthcare professionals follow appropriate coding and claims submissions. Doing so greatly reduces the risk of violating the five main federal abuse and fraud laws. These are:
- False Claims Act
- Stark Law
- Anti-Kickback Statute
- Exclusion Statute
- Civil Monetary Penalties Law
Our lawyers work closely with your office coding and billing staff to carefully inspect copies of your claims, looking for missing information and errors. We’re able to quickly test claims for a number of potential problems, such as:
- Billing for services or items not provided, or not provided as claimed
- Claims for services, medical supplies or equipment that were not necessary and reasonable
- Double-billing, which results in duplicate payments
- Billing for services as if they were covered even when they’re not
- Improper billing through misuse of provider identification numbers
- Billing individually for services that should have been billed as a bundle
- Improper use of coding modifiers
- Upcoding the level of service rendered
What’s the First Step to Compliance?
Your first step to compliance is contacting the legal team at Norman Spencer Law Group. We can begin with an analysis of your claims, which helps to identify erroneous charges and if non-compliant billing practices exist. Our rigorous process allows us to review documentation against posted charges, provide real-time feedback to your staff, and move forward to correct errors.
Our Medicare and Medicaid compliance clients regularly include physicians, dentist, pharmacists and other healthcare providers that are subject to claims audits. We’re dedicated to defending the professional licenses and careers of all healthcare professionals. If your practice is in jeopardy due to issues associated with Medicare and Medicaid claims submissions or fraud, contact us immediately. Call our office to schedule a consultation today.