The federal government has a message for physicians and others involved in billing for services under Medicare, Medicaid and other government healthcare programs: It's not going to pull any punches when it comes to protecting against overzealous and improper raids on its coffers.
The clues have been building for months. Congress last year allocated a $100 million budget increase for efforts to combat healthcare fraud and abuse. In recent years, the number of FBI agents assigned to healthcare fraud investigations grew sixfold and the number of people convicted more than tripled, according to the U.S. Justice Department, which last month referred to healthcare fraud as "the crime of the '90s."
Targets, thus far, have been rather high-profile, as illustrated by the burgeoning seven-state criminal probe of Columbia/HCA Healthcare Corp. hospitals. It was not surprising that the Columbia raid came on the heels of a government report asserting that Medicare loses $20 billion annually to fraud and waste. And just after a July Congressional hearing in which HHS Inspector General June Gibbs Brown rejected a call for a moratorium on billing investigations.
Further evidence of hard-ball government tactics exists in Medicare false-claim audits. After collecting $42 million in fines and restitution from faculty practice plans at the Hospital of the University of Pennsylvania and Thomas Jefferson University Hospital, the HHS inspector general's office is going to drop 16 audits but continue to pursue 33 others to determine whether teaching physicians ripped off Medicare by billing for work performed by residents as if it was performed by teaching physicians.
The feds also have made it clear they are willing to trade off leniency to academic medical centers willing to supply Medicare billing records of affiliated faculty practice plans.
And for good measure, the government's forthcoming model compliance plan for hospitals is expected to keep the heat on physician billing and medical records for DRG coding, individual Medicare Part B Claims and patient discharges. Those who have seen a draft of the plan say standards of conduct will require procedures to guarantee that bills are submitted only when appropriate documentation is maintained and is available for audit and review. Also, late entries or marginal notes in medical records must be noted and explained.
Executives of hospitals, medical groups and managed-care organizations need to send a loud and clear message that greed, fraud and ineptitude in billing will not be tolerated. And to make sure the message is received, physicians and others involved in billing should be given adequate training to help them avoid the pitfalls of double billing, bundling, upcoding, miscoding, DRG creep and improper discharge procedures. Doing anything less could jeopardize public confidence and threaten future funding levels.