Health care providers who bill Medicare and/or Medicaid are required to provide comprehensive and compliant claims for all services rendered and for all supplies/pharmaceuticals used in the delivery of patient care.
Penalties for non-compliant claims are significant. They include possible criminal prosecution (Medicare fraud), and civil and administrative enforcement, which can result in significant monetary fines and sanctions to exclude providers from treating Medicare and Medicaid patients.
With the trend toward lower reimbursement and stricter regulation, a claims/billing compliance program becomes an important survival tool for any medical practice. An effective compliance program demonstrates your practice’s good-faith effort to comply with the laws. It is designed to help you identify and prevent erroneous and fraudulent claims, eliminate billing mistakes, and reduce the chance of audit.
It is difficult to satisfy Medicare/Medicaid payer documentation and coding requirements necessary to receive appropriate payment. Therefore, medical practices should have a Medicare and Medicaid compliance program in place to identify problems and correct them before Medicare/Medicaid appear on the doorstep with a demand for overcharge repayment. Even for small practices, the repayment amount demanded can exceed hundreds of thousands of dollars, not to mention fines and potential criminal and civil penalties.
The Office of Inspector General (OIG) acknowledges solo and small group practices may not have sufficient resources to implement industry-leading practices. Nevertheless, the OIG requires such practices to address compliance in a proactive manner, which ensures state and federal laws are followed.
Your Medicare and Medicaid compliance program does not have to be perfect. It must be effective, however, and each practice has the burden of demonstrating its effectiveness to obtain the benefit of reduced culpability of a Medicare or Medicaid fraud claim.
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