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Medicare Fraud Enforcement More Than Window Dressing

Philip Betbeze, for HealthLeaders Media, December 31, 2009

One takeaway for healthcare entities, he says, is to be aware of that investigators are increasingly using data analysis techniques to look at warning signs that fraud may be ongoing at your organization.

"You may be on perfectly legitimate ground, but there are areas of the country and particular healthcare entities that are submitting claims grossly disproportionate to the rest of the country," Roark says. That means you should do that data mining work on your clinicians and subsidiaries as a proactive check on your billing, he says. Lots of times there may be good reasons for exceeding national averages, he says, but you should expect investigators to come calling if your billing stands out, and you should be prepared to answer their questions.

"The government is going to continue increasing the devotion of resources to healthcare fraud, which makes it more important than ever for hospitals and healthcare companies to have good compliance programs that can to detect fraud on their own," he says.

This is one area where you don't want to stand out from the crowd in 2009.


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Philip Betbeze is senior leadership editor with HealthLeaders Media.
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