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What Is Healthcare Billing Compliance?

Healthcare Attorneys and Billing Experts Assist with Medical Billing and Coding Questions

Of the many ways someone can get into trouble in the healthcare space, incorrect billing and coding are definitely on the top of the list. After all, all the efforts of a physician or business owner to be popular among patients, trusted by referral sources, and successful when it comes to the right diagnosis and treatment protocols would become useless without ultimately collecting reimbursement. Irrespective of whether this reimbursement comes from government programs such as CMS or private insurance carriers, caution is in order. Simple billing or coding mistakes can trigger draconian penalties under the False Claims Act and sometimes (in fact: increasingly) lead to federal criminal investigations, search warrants, and arrests for healthcare fraud.

Former Justice Department Healthcare Fraud Prosecutors

Oberheiden P.C. advises healthcare providers and billing companies alike to make sure no one will end up in the local newspaper. Billing mistakes are preventable. However, after more than a 1,000 prosecutions as former federal prosecutors and an equal amount of cases as now private defense counsel all team members of Oberheiden P.C. understand too well how quickly healthcare business owners and practitioners can get onto the radar of regulators and law enforcement—because they underestimate the consequences of incorrect billing. Oberheiden P.C. has helped providers across the United States with:

  • Healthcare Billing Audits
  • ZPIC and UPIC Audits
  • Medicaid Audits
  • Pre-Authorization Assistance
  • Collecting Receivables
  • Setting Up Compliant Billing Practices
  • Establishing Error Prevention Programs
  • Training Staff Members
  • Conducting Billing and Coding Audits
  • Taking Over the Billing

If you run a busy practice, have questions about billing compliance, or are just not sure if your current staff is adequately competent to submit 100% correct claims, give us a call. Experienced attorneys and certified coders from our healthcare compliance team are available to discuss your concerns—in a free and confidential consultation.

The Consequences of Wrong Billing and Coding

Don’t experiment when it comes to billing. With more than $ 400b in estimated healthcare fraud in the United States each year, don’t be surprised that federal prosecutors across all 95 U.S. Attorney’s Offices together with the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), the Medicare Fraud Strike Force, the Medicaid Fraud Control Unit (MFCU), and other agencies are vigorously and aggressively looking for any form of healthcare fraud. Specifically designed computer fraud detection programs and federal investigators are looking for “outliers” that is for providers with unusually high levels of billing, incorrect coding, and other avoidable schemes.

  • Billing for Medically Unnecessary Services
  • Billing for Services Not Provided
  • Billing Unreasonably High Levels of Care (Upcoding)
  • Billing for Mutually Exclusive Services
  • Billing for Services Not Covered
  • Billing for Out-of-Network Services
  • Failing to Collect Copays

For you, this scrutiny means, you cannot afford mistakes. You must make sure that your practice and your businesses are so well organized that violations of the False Claims Act do not occur—or, if they do occur because no one is perfect, that your business is protected against the perception of criminal healthcare fraud. Call Oberheiden P.C. attorneys today to find out how we set up billing protocols and compliance procedures that will shield you from mistakes and certainly from criminal investigations. In recent prosecutions the Justice Department applied the following statutes to bring formal criminal charges against physicians for alleged billing fraud.

  • False Claims Act (18 U.S.C. 287)
  • Healthcare Fraud (18 U.S.C. 1347)
  • Mail Fraud (18 U.S.C. 1341)
  • Wire Fraud (18 U.S.C. 1343)
  • Travel Act (18 U.S.C. 1952)
  • Conspiracy to Commit Medicare Fraud (18 U.S.C. 1347; 18 U.S.C. 371)
  • Conspiracy to Make False Statements Relating to Health Care Matters (18 U.S.C. 1035; 18 U.S.C. 371)
  • Conspiracy to Commit Healthcare Fraud (18 U.S.C. 1347; 18 U.S.C. 371)
  • Conspiracy to Commit Theft or Embezzlement in Connection with Health Care (18 U.S.C. 669; 18 U.S.C. 371)
  • Attempt or Conspiracy to Commit Health Care Fraud (18 U.S.C. 1349; 18 U.S.C. 371)
  • Conspiracy to Commit Medicaid Fraud (18 U.S.C. 1347; 18 U.S.C. 371)
  • Conspiracy to Unlawfully Use Health Information (42 U.S.C. 1320d-6; 18 U.S.C. 371)

Keep in mind that a single one of these accusations, say mail fraud pursuant to 18 U.S.C. 1341, alone would expose you to up to 20 years of imprisonment per instance of fraud. In light of these extreme consequences, it’s not worth it for you to gamble. Keep further in mind that non-criminal investigations of billing fraud participation can lead to CMS exclusion, license revocation, and enormous civil penalties. Whether civil or criminal, being accused of healthcare billing fraud can mean the death penalty for your career and your license. Call the experienced healthcare attorneys at Oberheiden P.C. to shift responsibility and to guide you so that you can sleep at night.

In-House Versus External Billing

Unless the in-house billing department is equipped with highly trained, certified, and experienced coders, medical billing should never be done in-house. Physicians, healthcare providers, and business owners should shield themselves from consequences of incorrect billing by isolating their medical practice and operations from billing and coding. While there may be a premium to pay to an outside vendor, the advantages can be enormous when it comes to lack of liability in case of an audit or investigation. Call Oberheiden P.C. how to structure a billing arrangement that makes economic sense and protects your practice against unwanted liabilities.

  • Oberheiden P.C. Billing Services
  • Oberheiden P.C. Coding Services
  • Oberheiden P.C. Auditing Services
  • Oberheiden P.C. Compliance Services
  • Oberheiden P.C. Healthcare Defense Services

Federal v. Non-Federal Billing

It is a myth to believe that billing for non-federal claims removes a clinic from federal jurisdiction. In the last few years alone, the U.S. Justice Department and the FBI have prosecuted a plethora of practice owners for healthcare billing fraud even though these businesses did not bill a single federal claim. The tools to do so are twofold. For one, the government invokes 18 U.S.C. 1341 and argues that each use of the mail system (or in case of electronic billing: 18 U.S.C. 1343) or the internet constitutes mail fraud. Additionally, recently the government added 18 U.S.C. 1952, also known as the Travel Act, to fortify its position that any and all healthcare billing fraud is federal fraud whether it is about federally funded patients, private insurance payments, or federal intermediaries and MACs.

Federal Programs

  • Centers for Medicare and Medicaid (CMS)
  • Department of Labor (Federal Workers Compensation)
  • Tricare (Military)

Private Insurance (PPOs)

  • Blue Cross Blue Shield
  • United Healthcare
  • Cigna
  • Aetna
  • Anthem etc.

Indications that Your Billing and Coding Are Wrong

Most billing mistakes are completely avoidable. A routine use of a particular code (e.g. Level 3 or Level 4 office visits, overutilization of lucrative procedures) can quickly catapult your billing practices onto the desk of an auditor or fraud investigator. Most clinics with billing problems will sooner or later experience one of the following concerns.

  • Lack of Trust in Billing Staff
  • Delegation of Billing to Simple Hourly Staff Members
  • Your Collection Rate Is Under 90%
  • Pre-Authorization Denials
  • Poor Documentation/Medical Notes
  • Recent Healthcare Audits
  • Overutilization of Specific Codes
  • Letters from CMS or Private Insurances
  • Lack of Certified Coder
  • Payment Suspension
  • Liability of Incorrect Billing Is on You, Not the Biller

More extreme indications include events such as the FBI executing a Search Warrant, you receiving a Grand Jury Subpoena, or OIG and FBI agents trying to interview current or former staff members. Oberheiden P.C. attorneys have defended clinics, medical doctors, and business owners of every form of healthcare clinic—from hospital, laboratory, pharmacy, physical therapy clinic, cardiologist, psychiatrists, dentists to name just a few—in federal billing fraud cases. Don’t wait until your healthcare billing arises to a formal investigation. Get advice today!

Medical Billing Compliance

Medical billing problems are entirely avoidable. The way to prevent mistakes (and to fix existing problems) is twofold: competent staff and effective compliance. Put bluntly, you can’t expect wonders from a person that you pay $ 15 or $ 18 per hour to handle your billing and coding. It will not work. Billing and even more so coding are very complex procedures that should be left to people with appropriate credentials such as Oberheiden P.C.’s certified healthcare coders.

Similarly, besides competent and trained staff, if you are just like most healthcare operations, you don’t have a compliance program. To be clear, you talk about compliance, and compliance is important to you, but the reality is that you do not have anything that would even remotely resemble a comprehensive, credible compliance program. If our assumption is correct, you are then among the 95% or so clinics that do not have a formal compliance program in place. In other words, you are operating in the second most regulated industry in the United States without any safety net, without any precautions, and without any demonstration of your good intent.

You are playing Russian Roulette. Today’s healthcare, unfortunately, means that providers have the burden of proof that they are compliant rather than, as it should be, the government having the burden of you being not compliant. Because the government will not use an x-ray machine to determine what your true intent was in terms of billing compliance, every claim that you submit that is false is your liability to deal with. Lacking any demonstrated efforts to show how you actually tried to be compliant (outside counsel, professional staff, certified coders etc.), you will know from here forward that your mistakes can be interpreted as criminal.

  • Let Oberheiden P.C. Establish Its Proven OIG Compliance Program that Eliminates Intent
  • Let Oberheiden P.C. Advise You with Its Team of Certified Coders and Professional Billers

The only way, and the only recognized way in healthcare to do so, is to have a compliance program. That is, you have written materials that demonstrate, for everyone visible, that you want to do things right. A compliance program stands for you having good intent. Not surprisingly, the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG), the two enforcement arms of the United States Department of Justice (DOJ) in healthcare fraud cases, expect every provider and every clinic to incorporate and apply recommended compliance materials. How to do so: Ask Oberheiden P.C. today.

How Oberheiden P.C. Can Help Your Business Avoid Billing Mistakes

Decades at the U.S. Justice Department, the insights of long-time healthcare fraud prosecutors, and exceptionally qualified billing and coding experts all make Oberheiden P.C. a go-to place when it comes to protecting healthcare businesses against audits, inquiries, and investigations. Our attorneys and consultants are available to discuss your concerns and work with you so that you can build your business without having to worry about the next audit, disgruntled employees, or incompetent staff members. Call Oberheiden, P.C. today at (214) 692-2171, including on weekends, or inquire online. Consultations are free and confidential.

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