Warning signs of a potential health care fraud investigation

March 1 2005 Larry Economos
Warning signs of a potential health care fraud investigation
March 1 2005 Larry Economos

Steps you need to take when they appear WHILE SOME OF THE WARNING SIGNS OF A POTENTIAL HEALTH care fraud investigation are obvious, others are not. Consider the obvious ones to be flashing red lights signaling you to stop and make sure you can move in safety before starting again. The less obvious warning signs are cau­tionary, yellow lights signaling you to slow down and proceed with care. Both require attention. The obvious signs have one thing in common: The insur­ance company. They are fourfold in increasing order of sever­ity: 1. A billed health insurance company notifies you of an inter­nal audit indicating unusual billing errors; 2. Representatives of a billed health insurance company ask that you submit billing records for their review; 3. Representatives of a billed insurance company come to your office asking to review records; and 4. A billed health insurance company demands that you pay back a significant amount of money for alleged improper billing. Signs 1 and 2 demand that you stop conducting business as usual and conduct your own internal audit of treatment records and submitted bills. Have an attorney involved to make certain your audit remains private and privileged. Discover your own errors and implement corrective measures. Allow a qualified health care fraud defense attorney to represent you in all corre­spondence and dealings with the insurance company. If you've handled signs 1 and 2 properly, signs 3 and 4 may never appear. If they do. you have laid a foundation to estab­lish your innocence due to billing errors rather than to inten­tional acts of fraud. The less obvious warning signs are three­fold: 1. Word gets around that a disgruntled employee is threaten­ing retaliation; 2. An employee notifies you that insurance claims have been submitted with significant billing errors; and 3. Either you or a partner keeps scanty treatment records, often not fully documenting all your services. When any of these signs appear, implement an internal re­view of your billing practices. Scrutinize some randomly se­lected submitted claims for billing errors, however small, and implement corrections for future submissions. Begin proper treatment documentation. If significant billing errors are found or suspected, consider yourself seeing a flashing red light and proceed to implement corrective measures, as outlined above, for obvious warning signs 1 and 2. Final word of caution: Make certain that your attorney is qualified and ex­perienced in health care fraud defense. Regardless of their experience level in criminal defense, health care fraud is a i specialized area that requires experi- ' ence and knowledge in Health Care , Financing Administration (HCFA) 1500 form billing, Medicare laws, state and federal criminal law, private insurance company adoption of billing regu­lations, contractual notice. Continuous Performance Tests (CPT) chiropractic coding, incidental billing practices, as well as cus­tomary health care billing practices. Not many attorneys have this experience. Ask about prior experience, including past contacts with qualified medical billing compliance officers. Don't be a lawyer's guinea pig. I Larry Economos, a civil and criminal defense attorney whose practice focuses on federal health care fraud defense, is a man­aging partner with Mills & Economos, LLP. Mr. Economos can be contacted via his website address, www.leconomoslaw.com, or by telephone at 800-456-0460, 704-375-9913. or 252-752-6161.