Healthcare Compliance: Saving Yourself from Fraud Investigation with Best Practices


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Most healthcare provider facilities get targeted for fraud investigation at any point in time. Their inability to comply with healthcare guidelines and reforms is because they are slacking on basic best practices. However, the good news is that as healthcare providers, you can save yourself from fraud investigation with best practices.

Assess Yourself

The first best practice is to keep a check on yourself. Assess whether you are doing everything right with healthcare compliance. There are three basic guidelines for self assessment:

  • Identify your weak points. Healthcare organizations need to conduct regular inspections as a best practice. This helps to ensure that duties have been distributed accurately and people are efficient. Administration, and other workers included in the organization must ensure they follow instructions appropriately and attend to patients according to requirements.
  • Regularly review the guidelines and reforms in the medical world. It is a best practice to stay updated with current changes and information related to latest medicines to treat people. If this is not done rightly, the risk of wrong treatments becomes higher which is bad for healthcare professionals and the patient.
  • Assess yourself on whether you are complying with the instructions and rules implemented by the insurers running the health insurance schemes. It is an important best practice to protect the interest of the patient and ensure he/she gets services appropriately.

What leads to an Investigation?

Upon investigation you may discover that your healthcare compliance is lacking all or most of the following.

  • Accepting whatever the insurance carrier offers with no query.
  • Accepting your patient’s account for settlement because you are working with a third party liability carrier.
  • You might be allowing the patient to keep an attorney to handle the third party liability claim and accept the settlement offered by the attorney.
  • Working with a limited number of healthcare providers and professionals like physicians and surgeons.
  • You do not read the Explanations of Benefits (EOBs) where the insurance carrier mentions the reasons for denial on their part.
  • Ignoring peer reviewer reports containing allegations of malpractice.
  • Discrediting affidavits containing alleged malpractices and reasons for denials.
  • Refusing to act in response to denials or allegations made against your facility.

Saving Yourself

If these basic best practices are lacking, here is what you can do to save yourself:

  • Involve knowledgeable people with proper know-how about medical and administrative laws to ensure healthcare compliance can be implemented correctly.
  • Establish a strong healthcare compliance format for medical laws, procedures and administrative protocols.
  • Set up a set of protocols to be followed at every stage where deficiencies have been identified or assumed to exist.
  • Set up a strong and flawless auditing process to assess medical and billing issues.
  • Ensure than there is a refund whenever you have defaulted in providing services to the satisfaction of the insurer or the insured.
  • Provide a hotline service to receive and attend customer complaints and concerns.
  • A Corporate Integrity Agreement between you and the investigator can save you from an investigation before you correct your weaknesses.

Healthcare compliance is an effective and highly recommended best practice to save yourself from fraud investigation.

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