If you’ve read TCI’s Medicare Compliance and Reimbursement Insider, then you already know the painful truth: If your practice receives Medicare reimbursement for services rendered to Medicare beneficiaries, and if you cannot prove medical necessity for those services, then you can be prosecuted under the False Claims Act (FCA).
The stakes are high. If you are found guilty, you can be fined up to three times the amount fraudulently obtained from the Federal Government (known as treble damages) and up to $11,000 per claim in civil penalties. You can also be permanently excluded from Medicare and Medicaid programs.
So, how can you avoid the government’s wrath? Here are four things you can easily do to keep your practice on the straight and narrow path of compliance, including three steps to follow if the unthinkable happens.
Medical necessity is a broad concept that explains why a physician chooses to perform a specific service for a patient. Basically speaking, any treatment that is medically necessary should be based on evidence-based medicine, which means your provider has used the most accurate and most recent research to inform decisions that will eventually result in the best possible outcome for a patient with a given condition.
To make life difficult, CMS does not define what it means by medical necessity, either in general terms or regarding specific conditions. However, it does provide guidelines as to what documentation you will need to prove that your physician has rendered services to a patient that are medically necessary. They include:
The Affordable Care Act (ACA) requires you to have a compliance plan if you treat patients who are enrolled in Medicare or Medicaid. Such a plan is critical if you want to avoid being accused of providing services to patients that are not medically necessary — or any other kind of medical fraud for that matter.
According to the Office of the Inspector General (OIG), a good plan involves the following components:
Finally, if you find any evidence of fraud through an internal audit, or if the OIG accuses you of fraud under the FCA, you should know the act contains a voluntary disclosure provision, which you can undertake using these three steps:
This act of good faith, along with a culture of compliance, will go a long way to soften the blow of any punitive sanctions should the OIG find your practice guilty of the charges.
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Nail down current Medicare regulations and secure your revenue with TCI’s best-selling Medicare Compliance and Reimbursement Insider 2018. Packed with vital compliance and reimbursement guidance — as well as Clip-and-Save tools, readers’ Q&A, case studies, and field-tested best practices — you’ll lock down compliance, master clean claim submissions, and hold onto every well-earned dollar of reimbursement.