Preventing Health Care Fraud and Abuse

Public and private payers are serious about rooting out fraud, waste and abuse in the health care system wherever it may occur. Pediatrics is no exception.

The vast majority of physicians work ethically, provide high-quality care, and submit appropriate claims for payment, but there are some who don’t. To address the few who exploit the health care system for personal gain, an array of laws has been enacted to combat fraud and abuse and protect the integrity of the health care payment system. The most important laws that apply to physicians are the False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law (Stark), Exclusion Authorities, and the Civil Monetary Penalties Law. Penalties and fines for breaking these laws are considerable sometimes even if there was no intent to do anything wrong.

Medicare, Medicaid, other federal health care programs and private payers rely on physicians’ medical judgment to treat patients with appropriate services and to submit accurate and truthful claims for the services they provide. Most physicians intend to do just that despite the complex and dynamic nature of payer coding and billing procedures which vary from payer to payer, policy to policy, state to state, and sometimes, month to month.

The best way to protect your workplace from fraud and abuse is to have a compliance program. Large health care organizations have had these in place for years and physician employees should be aware of their responsibilities in the program. With the passage of the Patient Protection and Affordable Care Act of 2010, physicians who treat Medicare and Medicaid beneficiaries are required to establish a compliance program---even small practices participating in federal healthcare programs.

A compliance program is a safety net. It establishes strategies to prevent, detect, and resolve conduct that does not conform to federal, state, and private payer health care program requirements, and the practice’s own ethical and business policies. Its aim is to make you confident that you are following all of the rules and regulations in a continuous matter and always working to improve. In addition, if there were to be a complaint, it allows you to demonstrate that you have and follow a process.

According to the HHS Office of Inspector General there are 7 elements of a compliance program.

• Conduct internal monitoring and auditing.
• Implement written compliance and practice standards.
• Designate a compliance officer, contact, or committee.
• Conduct appropriate training and ongoing education.
• Respond appropriately to detected offenses and develop corrective action.
• Develop open lines of communication.
• Enforce disciplinary standards through well-publicized guidelines.

Resources:

• For more detailed information see the AAP manual, Coding for Pediatrics. It is published annually and provides step-by-step guidance on preventing health care fraud and abuse in pediatric settings. 
• A Roadmap for New Physicians - Compliance Programs for Physicians