Medicaid and Medicare payments to physicians have undergone some serious changes in the recent years. Keeping up with the changes can make it difficult for practitioners to know exactly what they need to do, when they need to do things and how to handle certain challenging situations. It is imperative that they take the time to find out what they need to do to remain on the right side of the program.
Being accused of Medicaid or Medicare fraud is a serious matter. Avoiding this completely is the best thing that medical professionals can do since this preserves their ability to continue to accept these forms of payments for services rendered.
Ensure all claims are proper
There are a few different situations that might lead to a claim being deemed improper. Even though some of these might seem obvious, compliance is still important. You can't bill Medicaid or Medicare for:
- Services that are included in a comprehensive fee, such as evaluation and management for a same-day service. Establish a firm list of what is included in any comprehensive fee structures for your practice.
- Services performed by someone who isn't allowed to participate in a federal health care program. Periodically checking employee eligibility is a good idea.
- Services that weren't rendered. You can only bill for things that you performed. Even something a simple as billing for a wound dressing change is against the rules if you didn't do a full dressing change. You couldn't bill for this if you only replaced a Band-Aid.
- Services that are low quality. The services you bill for have to do something for the patient. Anything that is virtually worthless can't be billed.
- Services that aren't medically necessary. Anything that would be considered voluntary and that doesn't directly address the patient's medical needs wouldn't be billable.
- Services that aren't properly supervised. You can't have unqualified employees or trainees perform procedures and bill that out as if a qualified professional did them. Supervision and qualification of practitioners weigh heavily on the suitability of claims.
Use caution with medications
Some practitioners become so focused on trying to make sure they bill for everything that they forget about one important factor. You can't bill Medicaid or Medicare for medications that are administered in your practice if those were provided by pharmaceutical representatives. You should have something set up in your practice that clearly identifies any free samples that you receive so that you don't run the risk of accidentally including a sample on a claim.
If you do find that you are being investigated for Medicaid/Medicare fraud, be prepared for the process. This is the only way that you might be able to protect yourself and your practice.