The federal government, in 2015, penalized a pharmacist in Houston a sum of $5 million because of buying referrals from a single chiropractor who was operating eight different practices and getting a high level of U.S. Department of Labor disbursements. Further back, in 2012, there was a medical institution that mistakenly allowed search engine crawlers to have access to their patient database over a two-week period of server upgrades, resulting in a settlement of more than $2 million. The health care system is growing ever more complicated, and negligent and even illegal activity rise with this. Because of such incidents, health care providers must take certain steps to prevent malpractice and fraud from transpiring.

Understanding Laws And Regulations Around Health Care

The False Claims Act is abbreviated as FCA. It prohibits medical care practitioners from any insurance claim submissions for overpriced and/or inferior goods and services. Individuals who don’t report knowledge they have of such claims are considered as committing fraud. Federal government authorities have the power to find offenders as much as 3x the disbursements made, as well as $11,000 for every false claim.

The FCA offers enhanced protection for whistleblowers, even providing some of the recovered funds as a means of encouraging reports about fraudulent claims. Claims can be reported by patients, staff members, and even competitors. A ZPIC audit will ensure that a healthcare provider is operating within the law.

Make Sure Billing Is Accurate

Since patients and insurers put a lot of trust in their care providers, Congress mandates serious punishment for any false claims. The government has broad power to audit and investigate any fraud it suspects. In order to avoid inadvertent fraud, all care providers have to adhere to precise billing practices if they want to prevent inaccuracies, including overcharges or even claims for undelivered and undocumented services.

Keep Current And Appropriate Documentation

Care providers must maintain accurate records so that future treatments offer the greatest possible outcomes for patients. Accurate records will also help care providers establishing a legal defense if they face a malpractice suit.

According to the point of view of the Centers for Medicare and Medicaid Service, when a practitioner doesn’t document any rendered services, then such treatment never took place. As such, care providers need to maintain the appropriate documentation for any services that they deliver.

Avoid Any Referrals That Aren’t Necessary

Care providers that invest in other various practices face increased risk due to the Anti-Kickback Statute and Stark Law. Certain legislators think that arrangements like these promote an excess of referrals for the business partners of care providers.

Medical treatments that aren’t warranted not only waste insurance funds but also put patients in a needless state of risk. When a care provider enters a business relationship, they need to think about whether or not the potential partners are offering seriously underpriced buy-in, as that can be a warning sign a firm expects recompense in the form of undue referrals.

Keeping Up Transparency In The Physician Industry

The Department of Justice has done research alongside the Office of the Inspector General from the United States Department of Health and Human Services. This research showed that gifts received from medical industry manufacturers are able to influence the judgment of care providers. Transparency requirements in the physician industry are on the rise, due to both regulations from the Affordable Care Act and settlements with numerous pharmaceutical companies. The Advanced Medical Technology Association and the Pharmaceutical Research and Manufacturers Association have both created codes that can guide ethics for care providers and manufacturers alike.

Conflicts Of Interest Must Be Disclosed

The fraudulent activity might have legal beginnings but with conflicting interests. Care providers need to report things like this immediately. There are rules outlined about disclosing conflicts of interest from various entities, including universities, state agencies, the National Institutes of Health, and the Food and Drug Administration.

When care providers get gifts coming from partners in the medical industry, they need to think about how this particular relationship might impact their practice. They certainly need to keep up with legal compliance specific to their professional discipline and disclose such gifts to relevant authorities and boards. Care providers also need to get peer advice and think about how they might feel should there be public knowledge of such relationships.

Come Up With A Compliance Plan And Follow It

Care providers should try to prevent fraudulent activity through the creation and observance of a compliance plan, which is a specific practice that is ACA-mandated for anyone looking to keep their eligibility for Medicaid and Medicare. Voluntary compliance plans have seven distinct components:

1) Proper detection and the response of violations

2) Standards for compliance and practice

3) Election of a compliance officer

4) Continuing education and training

5) Internal monitoring/auditing

6) Communication throughout the organization

7) Disciplinary guidelines published widely

If you’re a care provider looking to establish plans, then check out resources from the Office of the Inspector General, specifically the Compliance Program Guideline intended for Individual and Small Group Physician Practices.