In the healthcare industry, there are rules that need to be followed in order to root out fraud, waste, and abuse. Unfortunately, these can be complex, draconian, and sometimes pretty confusing. When you file something incorrectly or incompletely, private insurance payers and government agencies alike can come to you for clarification in order to make sure that you are doing everything by the book. Navigating the maze of an audit or investigation can be tough, and we’re here to help.
With Medical Auditing Solutions, you have a team that’s dedicated to your operational success. Whether you’re a local general practitioner, a physical therapist, or another healthcare-related professional, a private audit or government inquiry is a serious situation, and it might be one that you are not fully equipped to handle. When that happens, speak with our office to make a plan to move forward.
Protect your practice’s interests. Call Medical Auditing Solutions today.
Reasons For A Government Investigation
There are many different situations that can warrant a call from a private insurer or a government agency, and when they do, it is important to make sure that you have answers. Ignoring a request from a government institution can be particularly problematic, so if you are struggling to make sense of your next steps, take the time to reach out to a trusted team about navigating the maze of an investigation.
If you utilize a mail room and/or other staff that open mail, it is critical these individuals understand anything from a payer in the form of a letter is critical/high risk and must be delivered and/or addressed by management immediately. Failure to respond by their deadlines can have devastating consequences and costs.
Common Reasons For A Government Investigation Or Audit
Suspicion Of Fraud- When organizations are paying for healthcare, they want to know that you are accurate with what you bill. They also need to know that you are performing necessary procedures and coding them in the appropriate way. The guidelines can vary by payer. This may not be a guideline; it could be something seen in claims that is “wonky” and instead of asking the payer starts an investigation such as a mismatching tax ID number and legal entity name doesn’t match what the payer and/or IRS records.
Provider data is an outlier- Meaning the practice is billing a high volume of a code or modifier that the payer has targeted as high risk. High reimbursed products that due to reimbursement rate, increases the audit risk.
Anti-Kickback Statutes- There are laws in place to prevent doctors from receiving financial incentives for the referral of a patient whose services are paid by a federal program like Medicare and Medicaid. There are many examples of illegal remuneration, this is a good reason to always talk with your healthcare attorney before entering into any relationship with a lease, distributor, billing company, other healthcare providers or pharmacy manufacturers or distributors. There are some attorneys on our website, but our list continues to grow in various states. There are both federal and state laws related to this practice and violating them can lead to fines or even jailtime.
These are just a couple of the many reasons a government agency might want to talk to you. If you have been contacted by CMS, The Office of Inspector General, or your state’s Attorney General’s office, let us know. We can help you to make a plan.
Navigating The Maze Of The Insurance System
We know that in the United States, our healthcare system is complex, to say the least. As a healthcare provider, you have to know compliance on top of your specialized health knowledge, and that can be a tough thing to do. If your team could use a refresher on their compliance, we’re here to help with that, as well.
And when a government entity asks questions, we’re here to help.
Navigating Background Checks
It is critical to background check via vendors, third party biller, employees via criminal database, sanction and exclusion database. You can find the sanction database via our website. There can be felonies other than healthcare related which would not automatically get someone added to the sanction provider lists. Additional information to request from billing companies, verify company formation, does their contract require a minimum amount of insurance coverage, and ask for a copy of their insurance certificate. We can help you verify the credentials and reduce risk. If you use another consultant, ask them for help.
Find Your Path Forward With MAS
A government or other commercial payer investigation or audit can be scary. Our team is ready to work with you and your attorney in navigating the maze of our complex health insurance system, so call Medical Auditing Solutions at (972) 459-1508 today.