Healthcare Compliance – Reducing Fraud Risk


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The main reason for implementing healthcare compliance is reducing fraud risks and abuse. The most important best practice is complying with laws and regulations which are imperative for risk management. There are recommended initiatives and programs which one can employ to achieve best practices in healthcare.

Healthcare professionals are constantly on their feet helping citizens with treatments for one ailment or the other, accidents and giving birth. However, there are some risk management laws they need to abide by to ensure the best practice in their profession. Therefore there are healthcare compliance issues with could have negative consequences on healthcare providers if there is no compliance.

Throughout the Unites States there are healthcare compliance guidelines. These help healthcare providers with guidance on a framework for handling appointments, surgeries, billing, coding of treatments, referring, and managing health insurances. The database of the people entitled to receive healthcare is too large and people tend to take advantage of this. There have been various fraud cases at different levels due to failure to comply with best practices. Most lapses leading to fraud in healthcare are poor management of records, incorrect billing, missed entries and miscommunication.

Professionals in healthcare are also expected to comply with best practices in order to maintain adequate risk assessment, ethics of practice, referral laws and patient rights. Professionals in healthcare must be able to manage their patients in compliance with these regulations to maintain high standards and patient satisfaction. There must be proper documentation of the bills which must be accessible during audits. Additionally, healthcare compliance reduces the risk of maltreatment, malpractice and abuse of patient rights.

Measures taken to Reduce Fraud Risk:

In order to reduce the risk of fraud, certain healthcare reforms have been implemented in the United States. These include:

  • The RAC, Recovery Audit Contractor program has been extended to Medicaid and Medicare programs.
  • Incase of alleged fraud the HSS and State agencies will be authorized to suspend the Medicare and Medicaid payments to providers and suppliers. Suspension will last during the investigation of fraud and end upon clearing of doubts.
  • There will be a CMP (Civil Monetary Penalty) of $50,000 for any fraudulent payment or record under the healthcare program.
  • Each day the provider or supplier denies access of the HSS to conduct audits, evaluations or investigations about their best practices; they will be fined $15,000.
  • The amendment to AKS (Anti-kickback Statue) says that the person involved in violating the healthcare compliance does not need to know the prohibition of specific actions. Additionally, the government is not required to prove the intent of the person or organization to commit the violation.
  • The Stark Law now prohibits established hospitals from expanding their facilities as well ownership.

There is a SRDP (Self Referral Disclosure Protocol) allowing providers and suppliers to disclose actual or potential violations of the stark law. Upon self disclosure the penalty will be reduced.

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