Avoiding Fraud and Abuse Charges in Medical Billing

Avoiding Fraud and Abuse Charges in Medical Billing

Gainsharing in medical billing is highly scrutinized. The HHC Office of Inspector General is very suspicious about gainsharing activities with healthcare providers. There are three areas hospitals should focus on in order to prevent medical billing fraud allegations.

Improper gainsharing agreements are borderline fraud in medical billings. The three things hospitals can do to prevent any fraud charges are having sufficient quality controls implemented, promoting accountability, and limiting payments that lead to referral pattern changes. If all three of these elements are satisfied, your hospital will have no problem providing trustworthy medical billing.

Currently there is a CMP (civil monetary penalty) that prevents kickbacks. Gainsharing arrangements can potentially aid these kickbacks which look suspicious in medical billing. Kickbacks affect the quality of patient care. These agreements are only concerned about the medical billing bottom line. The gainsharing agreements could severely effect the Medicare patients significantly. The Centers for Medicare & Medicaid Services realizes this and is trying to put a stop to the agreements as soon as possible.

In order to run a hospital successfully, two things are necessary: quality of care, and profitability. Without one element, the other would also fail. Proper medical billing procedures can help accomplish one of these traits. As long as your hospital stays accountable, limits payments that lead to referral pattern changes, and implements quality controls, it will be successful. The key to fraud and abuse prevention is honest medical billing with strong integrity.

A medical billing firm can provide the level of integrity needed. Their job is to uphold correct policies and procedures and to make your facility profitable. Hiring a medical billing company would not only help with regulation control, but would also save you money. The less work your staff need to do, the less money you need to pay in salaries. To avoid fraud and abuse charges, a medical billing firm is the way to go.

View all Articles by: Melissa Clark, CCS-P