Article summary of tips for physicians to avoid inadvertent Medicare fraud.

The laws involving fraud are frequently tightening and enforcement is getting stricter.

The laws involving fraud are frequently tightening and enforcement is getting stricter.

Mismanagement of claims, paperwork falling through the cracks and unintentional errors can trigger investigations leading to liability for Medicare fraud. Intent is not a factor and even simple oversights can trigger fraud liability, regardless of whether there was any intent to defraud the U.S. Government. Investigators have a duty to follow up on claims of healthcare fraud. The following is an article summary of, “6 Ways to Avoid Unintentional Medicare Fraud,[i]” which was recently published by Health Leaders Media.

The law regarding fraudulent claims is strict and investigators closely follow potential fraud claims.

Traditionally, the healthcare fraud offenders were billing for treatments that they did not provide. The laws involving fraud are frequently tightening and enforcement is getting stricter. Simple mislabeling and inadvertent errors can cause fraud investigators to start looking for other incidents of file and claims mismanagement. A keen investigator could suspect that simple office errors could be made on purpose to hide other intentional bad acts such as filing claims for made up patients who never actually visited the office or received treatment.

Here is a summary of tips to avoid making inadvertent mistakes and Medicare fraud:

  1. Do not have an expired medical license when billing. If the physician or staff member has an expired license, there could be a finding of fraud, even though services were properly provided. Even if you are unaware of a gap of time while renewing a license, there could be fraud liability and convictions;
  2. Physicians responsible for supporting professionals, as required by law, should supervise very closely. Not being in the same room or space to oversee the performance of services could be construed as a failure to supervise, and that can be fraud;
  3. Medications not picked up by patients must noted and any claims for the costs of medications should be credited back and the claims documentation should be properly noted. Claims for medications not picked up could be fraud;
  4. Physicians should very carefully review all the billing performed by a billing clerk. If there are errors in the billing, the physician should catch them and is responsible. For example, if a billing clerk assumes the doctor performed services and that is not verified it could be fraud;
  5. Giving poor patients coupons or food can be considered a kickback and that is not likely construed as harmless charitable activity. While the act of giving might seem like goodwill, it might also be considered a bribe to attract the person in for healthcare services;
  6. Do not work too quickly and risk the appearance of overbilling. Estimated times for billing even routine activities may be take 20 minutes, but sometimes a professional is able to perform many of those activities in less time. Being efficient as one might describe, could also be described as fraud when the numbers do not add up and there are too many routine activities billed in too short of a time.

There are many potential pitfalls in the healthcare industry when it comes to Medicare billing. Not every investigation leads to a finding of fraud. It is important to consult an attorney if you are involved in a fraud inquiry. Attorney Michael V. Favia is experienced in healthcare law and litigation and can assist in these types of cases. Michael V. Favia & Associates are available to help and meet for client consultations with offices conveniently located in the Chicago Loop, Northwest side and suburbs so you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates’ professional licensing work, please visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter.


[i] Health Leaders Media: 6 Ways to Avoid Unintentional Medicare Fraud. By Greg Freeman, Jan. 30, 2014.

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