The responsibility for fraudulent claims rests with anyone who “knows or should know” that the services were not provided as claimed, and the penalties can be severe. The Medicare audit can be a horrendous experience. Every medical practice needs a compliance plan to guard against fraud, whether intentional or inadvertent.
MEDICAID AND MEDICARE
MEDICAID
Medicaid is a program that pays for medical assistance for certain individuals and families with low incomes and resources. The Medicaid program is jointly funded by the federal and state governments to assist states in furnishing medical assistance to eligible needy persons. Medicaid is the largest source of funding for medical and health-related services for America’s poorest people. With broad national guidelines established by federal statutes, regulations and policies of each state:
In order to avoid this you should:
• Develop standards and procedures for billing and coding
• Designate a “compliance officer”with oversight and responsibility
• Conduct effective training for your employees
• Develop a mechanism for employees to report suspected violations
• Establish its own eligibility standards
• Create monitoring and auditing systems
• Determine the type, amount, duration, and scope of services
• Investigate problems and take disciplinary action
• Set the rate of payment for services
• Initiate corrective action
• Administer its own program
HEALTHY LOUISIANA Healthy Louisiana is Louisiana’s name for its new expanded Medicaid program, which provides health insurance coverage to more than 350,000 working Louisianans who could otherwise not afford health care, while bringing both jobs and economic development to the state. On January 12, 2016, Governor John Bel Edwards signed an executive order (JBE 16-01) to begin the process for expanding Medicaid in Louisiana no later than July 1, 2016. Expansion has made Medicaid available to more than 400,000 people living in Louisiana who did not previously qualify for full Medicaid coverage and could not afford to buy private health insurance. By receiving Medicaid coverage, these Louisianans, many of them working adults in important industries like food service and construction, are finally able to get the regular, preventative, and primary care that best promotes health and wellness.
MEDICARE
Medicare is a health insurance program for aged persons to complement the retirement, survivors and disability insurance benefits under Title II of the Social Security Act. Medicare covers persons age 65 and older. Persons under 65 may be covered if approved for disability or if they have certain diseases. Medicare consists of hospital insurance (Part A), supplemental medical insurance (Part B), prescription drug coverage (Part D), and Medicare Advantage plans, which offer beneficiaries a private health plan option.
MEDICARE BILLING COMPLIANCE
Filing false medical claims is a crime. The U.S. Department of Justice considers combating health care claims fraud and abuse among its top priorities. A false claim is when any statement made to secure reimbursement is inaccurate. This includes even seemingly minor errors, such as dates, provider numbers or places of service.
WHO CAN APPLY?
The most common types of fraud include:
Any adult who meets the eligibility criteria listed below are able to enroll in Medicaid under the expansion.
• Billing for services not provided
• Ages 19-64 years old.
• Misrepresenting the diagnosis
• Has a household income less than 138% of the federal poverty level. Visit LDH.LA.gov for more information.
• Soliciting, offering, or accepting a kickback
• Unbundling charges
• Doesn’t already qualify for Medicaid or Medicare.
• Falsifying any medical documents or records
• Must meet citizenship requirement.
• Submitting duplicate reimbursement claims
To enroll under expanded Medicaid, it is not necessary to have a dependent child in your household. There is no asset test.
• Billing for higher-level procedure than the one performed
26 La State Med Soc NEW PHYSICIAN’S GUIDE
La State Med Soc NEW PHYSICIAN’S GUIDE 27
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