With an estimated $60 Billion wasted in Medicare fraud annually, our government has enacted various laws in an effort to reduce healthcare fraud. They are going after healthcare fraud in a major way as part of the effort to balance the national budget, and there are a few new programs that are making a significant difference in healthcare reimbursements. They are RACs, MACs, ZPICs and Strike Forces.
Recovery Audit Contractors (RACs) find and correct current and future improper payments and implement changes that will prevent this from reoccurring.
Medicare Administrative Contractors (MACs) write reimbursement checks on behalf of CMS. CMS created the “Comprehensive Error Rate Testing” (CERT) program to assess whether MACs are paying claims properly.
Zone Program Integrity Contractors (ZPICs) are responsible for detecting, deterring and preventing Medicare fraud and abuse.
The Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of data analysis techniques (data mining of Medicare claims).
The above agencies perform audits and have strict appeals processes. With the passing of the HITECH Act, penalties have become sizable. Simple repayment of the disallowed claims is no longer the remedy when you get into hot water with these agencies. Repayment, penalties and prosecution are the remedies today. Additional programs are being implemented and still more programs are being developed. Providers looking to defraud the system should be fearful.
But even though it can seem like governmental agencies are “out to get you,” the bottom line is that all the above agencies shouldn’t have a negative impact on your practice if you’re an honest and ethical provider submitting compliant billing. These agencies understand the difference between random mistakes and intentional fraud. Regularly and carefully monitoring claims you submit, partnered with a strong compliance plan can help prevent serious billing issues. It is true that complying with ever-changing regulations is challenging, but being a provider treating patients is only part of today’s reimbursement process. Billing sounds like a simple process, but it has become very complicated. Proper medical billing requires accurate coding, a solid understanding of billing guidelines, and supporting documentation. Billing has become a specialized profession, and I highly recommend hiring a third party professional billing company that has an extensive background and experience in your specialty. As the old phrase goes “An Ounce of Prevention is Worth a Pound of Cure”.
