This article appears in the February 2014 issue of Managed Care Contracting & Reimbursement Advisor.
As physicians push to maximize their revenue, it can be easy to stumble into fraud through simple oversights and failing to understand how regulators look for claims that don't quite add up. Don't rest on the fact that you have no intention to defraud the government; sometimes you can get in just as much trouble by accident.
There are many scenarios in which a practitioner can be charged with healthcare claims fraud, even when he or she thinks a legitimate service has been provided and billed accordingly, cautions Riza I. Dagli, JD, who previously held several key posts within the U.S. Office of the Attorney General, including director of the Medicaid Fraud Control Unit, where he supervised investigations and prosecutions of Medicaid and Medicare fraud, healthcare fraud, patient abuse and neglect, off-label marketing, and kickback litigation. He is now a partner in the health law practice at Brach Eichler in Roseland, N.J., and chairs its criminal defense and government investigations practice.
Traditionally, healthcare fraud has been considered to be billing for treatment you did not provide, Dagli says. That definition has changed lately and physicians must understand how good intentions will not necessarily keep them out of trouble.
"Nowadays the laws are so strict that people are more careful not to do phantom billing, but unfortunately there are situations where you provide a service to the patient, the patient leaves, and all of a sudden you're in a fraud investigation," Dagli says. "Physicians have to be mindful that mismanagement or sloppy business practices can land them in a lot of hot water because prosecutors are looking for other manner of fraud besides making up a patient name or billing for someone who never really came to your office."