Why should a provider comply with all the confusing regulations? There could be business interruption, reputation at stake, and could possibly be fines.

But how would they ever find a Provider?
RAC (Recovery Audit Contractors)
  • These are Medicare’s newest weapon…the “hired guns”
  • For every dollar spent, RACs typically get $40 returned to Medicare’s coffers…(They get a “cut” of the savings)
  • Staff member
  • Provider fit a profile
  • Statistics
Qui Tam lawsuit
  • Anyone (a whistle-blower) that can help the government prove it’s case against you can file a qui tam lawsuit
  • That “helper” gets 25% of what is recovered.
  • Disgruntled employee?
Routine audit
  • Medicare is committed to auditing EVERY physician this year.
  • If you have been asked to provide information and documentation on 8 charts…this is a routine audit. Don’t panic
  • Make sure you comply in a timely manner.
  • Manners count
  • Don’t trust your staff to “just handle it”.
  • Look things over before it’s sent in
  • See if you can discern a pattern
  • Failing a routine audit may invoke a focused audit
They already know what they’re looking for YOU.
What are they looking for?
  • Billing for services that were not provided
  • Over coding (with intent)
  • Over coding (accidental/inadvertent)
What happens if I’m caught over coding by accident?
  • Most common is an educational “event”
  • You MAY be asked to send back the money
  • You MAY incur fines and penalties
  • Send all the “ill-gotten” money back and then request the lesser amount.
What happens if I’m caught over coding intentionally?
  • Return the money
  • Pay a $2000 fine PER LINE ITEM
  • Legal fees ($100K-300K)
  • Loss of work time
What happens if I’m caught billing for services I didn’t provide?
  • Pay back the money
  • Fines
  • Exclusion from Medicare/Medicaid
  • Loss of medical license
  • Tax evasion charges
  • Prison time
  • ALL of the above?
What happens in a raid?
  • If you see more than 2 large USPS vans in your parking lot….THAT COULD BE AN OMEN!
  • They probably contains FBI agents, OIG investigators, Postal inspectors, local police, etc.
  • Seizure of records and/or assets
  • Disruption of business
  • Your good name all over the news
Let us help you avoid all this by guiding you to doing right kind of coding and billing.