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All the information you ever needed about healthcare fraud and the regulations

There are several key definitions and various rules that you need to keep in mind regarding healthcare malpractices and other billing offenses. It is in your best interest to be aware and informed about the various frauds and abuses, along with the legal penalties that include the Anti-kickback Statute and the False-Claims Act. For more information, get in touch with The Healthcare Fraud Group

Here are all the main types of healthcare fraud that are prevalent globally,

  • Submission of falsified claim documents and misrepresentation of health issues, procedures performed and treatment bills to acquire a reimbursement from an insurance provider or person
  • Solicitation, receiving and offering of remuneration for referrals with the sole purpose of monetary gains
  • Allowing for various prohibited referrals with respect to special health services

There are multiple instances of healthcare abuse as well that includes falsification of claims and bills in case of a no-show for an appointment, billing for services that weren’t furnished as well submitting a complex application for higher reimbursement. 

What is the problem?

The greater the extent of healthcare abuse, the higher is the unnecessary cost that is generated for an individual or the health insurance service provider. Keep in mind that with medical abuse, there are various problems, and the major one is the prevention of patients from receiving industry standard and high-quality treatment and medically necessary procedures

What are the federal laws and acts in place?

Healthcare abuse results in severe and crippling criminal and civil liabilities. Federal policymakers have come up with the following regulations to keep the medical and healthcare abuse in check. Let us have a look at them. 

The False Claims Act

This federal law makes provisions for a civil liability case on an individual or organization that submits a false or fraudulent claim document with the sole purpose of generating revenue. There is no need to prove specific intent for the person/s committing the fraud. 

The Anti-Kickback Statute

This federal law targets all individuals and groups who pay, receive, and solicit referrals with the sole purpose of generating a kick-back for the services and items offered. 

Law for Physician Self-Referral 

This Federal legislation is all about prohibiting medical practitioners from providing referrals for specific healthcare programs where the provider or a family member is a stakeholder or an owner. 

Keep in mind that there are crippling economic sanctions and penalties as well as provisions for long-term imprisonment if the proof of guilt can be found. 

Steps to combat healthcare fraud

Here are some of the critical steps that if implemented correctly, can help curb out healthcare fraud.

  • Distribution of a code of conduct pertaining to the standard of treatment and policies to the hospitals and medical service providers
  • Addressing the areas under suspicion of potential fraud including the claims management and the financial relationship with the health insurance service providers
  • Presence of a Chief Compliance Officer on the hospital premises at all times to monitor the compliance with the code of conduct
  • Education and training programs for the medical staff
  • Maintenance of an official government process to file complaints and reports by individuals
  • Investigation of problems, claims, and audit by a third-party agency to reduce issues related to healthcare fraud and abuses

By joining forces, together we can curb out the healthcare frauds maligning our medical system. Let us all take the pledge to root out the problem once and for all.

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