Like the federal government, state governments, and private insurers continue to crack down on healthcare fraud, insurance companies and legal experts alike are seeking answers as to why.
According to John LeBlanc of Manatt, “The government is aggressively prosecuting healthcare fraud because the taxpayer picked up almost $30 billion in fraudulent claims between 2009 and 2011.”
With such a significant sum of money on the line, it is unsurprising that hospitals and insurance companies alike are bearing the brunt of investigations into fraudulent practices. Yet, as LeBlanc notes, “statistics show that more than 12 percent of all healthcare expenditures are lost to fraud.”
Although there are certainly hospitals guilty of committing acts of fraud, insurance companies have not been immune from allegations. According to LeBlanc, “Hospitals continue to face stiff audits by private insurers, Medicare and Medicaid. In addition, the Department of Health and Human Services Office of the Inspector General (HHS-OIG) has launched a nationwide effort to provide guidance and assistance to hospitals to reduce the risk of erroneous billing.”
An example of HCA being investigated for fraud
In 2002, an investigation was opened into Columbia/HCA Healthcare Corporation, a multibillion-dollar hospital corporation that eventually pled guilty to fraud charges. As a result of the investigation, HCA paid several fines for fraudulently billing Medicare and Medicaid while one subsidiary pleaded guilty to 14 felony counts of fraud against the government.
According to LeBlanc, “Hospitals are facing increased scrutiny by both private insurers and federal authorities. As a result, hospitals are at increased risk for false claims violations, especially because of the recent trend of hiring physicians to work in hospital-owned entities. Furthermore, hospitals must closely review their compliance programs and ensure they have an appropriate compliance structure.”
In addition to increased scrutiny from the government and private insurers, LeBlanc notes that “private payers are increasing their audits of physician practices, looking for opportunities to deny claims under the guise of fraud-based investigations.”
For this reason, medical practices must also stay vigilant when submitting claims to avoid being incorrectly accused of fraud. In addition, LeBlanc says, “physicians must remember that they are at risk of having claims denied under the False Claims Act if their billing practices give even an inadvertent appearance of fraud.”
As more and more entities continue to fall under the scrutiny of federal, state, and private investigators, LeBlanc concludes that “the best way for hospitals and physicians to avoid an investigation is to stay current on their claims submissions and maintain compliance programs that are updated to address evolving fraud risks. By being proactive, hospitals and physicians can protect themselves against allegations of fraud.”
LeBlanc also adds that “the only way to truly protect against False Claims Act liability is to ensure compliance with all applicable laws and regulations. This means having a compliant billing and coding process, as well as a comprehensive compliance program. By doing so, hospitals and physicians can show the government and private payers that they comply with all laws.”
With the rise of fraud investigations, healthcare entities must stay aware of their practices. By doing so, hospitals and medical practitioners can avoid increased scrutiny and prevent further losses to the federal government.