With increasing federal resources allocated to healthcare fraud investigations, your healthcare firm’s billing practices must be faultless. In running your healthcare practice, you may not have a clear insight into the billing procedures that lead to a federal investigation and potentially criminal prosecution for healthcare fraud. 

Lowther | Walker’s experience in healthcare fraud billing investigations and compliance analysis for healthcare providers places our lawyers in a prominent position to advise on legal billing within the healthcare space. And within this post, we’ll explore more about the billing practices that may expose your business to a fraud investigation.

Incorrect Billing Codes

The simple addition or subtraction of a digit may increase the potential of your company facing a fraud investigation. Submitting incorrect billing codes is a violation under the FCA for “knowingly submitting false claims,” and you then require the legal guidance of a healthcare fraud defense attorney to investigate and identify the cause of the billing code error.

Modifying Billing Codes 

Modifiers help explain more about a specific code and the related product or service for billing. However, the CMS only allows the modification of billing codes under narrow circumstances and has a detailed procedure for modified billing code submission. Failure to adhere to the CMS guidelines may constitute billing fraud.

Double Billing

Examples of double-billing cases include billing the same federal healthcare agency for the same service more than once and billing multiple government programs for the same services. Double-billing can occur when your administrative team works with patients using different government programs, as team members may compile all patient-specific services under one billing structure.

Billing for Not-Medically Necessary Services

Federal programs such as Medicare only provide services deemed medically necessary. If a CMS healthcare audit finds you or your team have billed for a service they deem unnecessary, you can face further investigation and potentially criminal charges for healthcare fraud. 

Steps Healthcare Organizations Can Take to Reduce Legal Risk of Billing Errors

Upgrade Documentation Standards

One of the most common reasons healthcare providers fail audits is a lack of documentation. If your documentation falls short of CMS and HHS standards, a healthcare fraud defense firm can review your practices and enhance them in compliance with the latest regulations.

Following the Patient-First Standard

Any billing process must serve two purposes – it must comply with the regulations set forth by the regulators and meet the patient-first standard. Failure to meet this standard places you and your healthcare business at risk of penalty from the DOJ for not protecting patient rights. Any decision, such as a treatment recommendation or a referral, must solely be made in the patient’s best interests. 

Securing Legal Security in Billing Contracts

Most healthcare professionals now hire outside agencies to manage their billing procedures. The billing company you work with should have a strict legal protection policy, limiting your level of liability for billing mistakes made by their team. Confirm your agreement confers ultimate legal responsibility on your billing provider, and clarify any liability issues with your provider before finalizing working contracts.

Booking Compliance Services from a Federal Healthcare Law Firm

With potential civil penalties that include fines of up to $10,000 per error and the potential for criminal penalties for making fraudulent claims under the False Claims Act, healthcare providers should proactively seek compliance services from a lawyer with proven experience in federal healthcare compliance. Lowther | Walker is the U.S. leader in healthcare fraud defense and billing compliance, helping medical providers analyze their current billing structures and meet the highest standards under Federal law.

Call Lowther | Walker for a Free Healthcare Billing System Consultation

Federal defense lawyers Lowther | Walker hold years of experience defending medical providers in billing fraud cases. Our team has an encyclopedic knowledge of healthcare law and can help you and your team improve your billing practices based on the latest regulatory frameworks.  We serve medical professionals across the country, responding to DEA investigations with urgent defense services in Arizona, Alaska, Florida, Georgia, Alabama, Kansas, and Oklahoma.

Call Lowther | Walker via (404) 496-4052 for your free, confidential consultation for clear answers to your healthcare billing compliance questions.