Federal Government Aggressively Pursuing Health Care Fraud

July 5, 2013Articles
The Federal Government is using every tool available to fight health care fraud and recover overpayments from health care providers. According to the United States Department of Health and Human Services and Department of Justice Health Care Fraud and Abuse Control Program Annual Report for FY 2012, the Federal Government recovered over $3 Billion in health care fraud judgments and settlements. In its Semi-Annual Report to Congress for the first half of FY 2013, the Office of Inspector General expects to recover over $3.8 Billion in audit receivables and investigation receivables from health care providers. As a result of the Federal Government’s aggressive auditing and overpayment recovery, and in order to ensure compliance with Federal program billing payment requirements, including Medicare and Medicaid, health care providers have begun performing self-audits on a sample of claims to be submitted.

Proactive self-audits serve multiple functions for health care providers who elect to participate in them. By auditing a sample of records, a provider is able to determine whether its records would support a finding that the services ordered and performed were necessary and reasonable. The self-audits allow providers to conclude whether their health care records contain all appropriate and necessary information to allow receipt of proper reimbursement. Finally, the self-audits permit providers to fully review the information and flag any potential problems in how the health care information was recorded. If a health care provider identifies a potential problem from the sample selfaudit, the provider should expand the sample to determine if a pattern or trend involving poor or inappropriate charting exists.

If a health care provider is presented with a charting problem, the health care provider should take action to eliminate the problem immediately. The health care provider may need to conduct more in-service training for personnel,
upgrade record keeping methods, bring in an outside consultant to evaluate how and what information is recorded in the record, and possibly take disciplinary action, as described in the provider’s personnel manual, against non-compliant staff.

If a health care provider fails to take corrective action once a problem is identified, it may face harsher penalties. Once a problem is identified, providers should make every effort to remedy a problem and minimize the potential of submitting improper claims to the Federal government.