Compliance and billing fraud are major issues in the healthcare industry today.
In 2016, the Medicare Fraud Strike Force conducted the largest billing fraud takedown in history, both in terms of the number of defendants charged and loss amount.
The investigation resulted in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings.
Compliance enforcers are diligent in their efforts to ensure that all medical providers and practices are complying fully with all rules and regulations.
To make sure that your office is in compliance with the rules and regulations of the ever changing medical field, we recommend conducting regular internal audits.
What is an Internal Audit?
Internal audits involve reviewing your office’s policies and procedures to identify any inappropriate documentation, coding and billing practices. Errors in these areas are not just simple mistakes. If not caught and fixed, they could put your medical providers and/or practice at risk for fines or even criminal charges.
Regular audits can reveal inaccuracy issues, such as outdated codes or even fraudulent billing. These audits provide a quality assurance process that helps organizations obtain proper reimbursement and maintain regulatory compliance.
Internal Billing Audits
The office of the United States Attorney General takes billing fraud very seriously. Billing fraud happens when healthcare providers bill insurance or Medicaid of services and treatments that the patient never received.
The False Claims Act is frequently invoked by prosecutors against suspects accused of overcharging Medicare, Medicaid, and insurers. The act imposes civil and criminal consequences and makes it a crime to knowingly submit a false claim to the federal government. If convicted, defendants face up to five years in prison and a fine of $250,000.
Internal billing audits help ensure that appropriate payments and claims are being made, as well as compliance with applicable laws. Regular monitoring of internal policies and procedures is the most effective way to prevent health care fraud. The Office of the Inspector General encourages medical practices to perform internal billing audits at least once a year.
Regulatory Change? Perform an Internal Audit.
Regulatory changes can significantly complicate coding and billing. For example, according to Provident Management Consulting, the healthcare industry has witnessed sweeping regulatory changes in the last decade alone, including:
- Compliance with the Patient Protection and Affordable Care Act (PPACA),
- Implementation of International Classification of Diseases, Tenth Revision (ICD-10),
- Demands related to Recovery Audit Contractor (RAC), and
- Security and privacy issues related to the increased use of social media, cloud based technology and smart-devices.
According to Physicians Practice, audits can be used to determine if:
- bills are accurately coded and accurately reflect the services provided
- documentation is being completed and correct
- services or items provided are reasonable and necessary
- any incentives for unnecessary services exist.
Audits will show where your practice needs to focus on improvement and education.
How Often Should You Audit?
Industry experts recommend an annual audit, but we believe that monthly audits add significant value to any organization.
Monthly audits help you catch errors more quickly, which means you can implement procedures to reduce those errors faster. Insights from monthly audits also give you areas to focus on for ongoing staff training and education.
Another reason to conduct more regular audits is that regulatory bodies often make updates more than once a year. For example, the American Hospital Association releases quarterly coding updates.
Need a Hand?
By committing to conduct regular, ongoing internal audits, your office will be able to rapidly identify areas for improvement, reduce lost revenue and increase accountability.
MED3000’s regulatory experts can help provide education, training and recommendations for improvement. Contact us today to find out how our regulatory experts can support your practice!
