Due Diligence: Your Greatest Ally in Healthcare Fraud Prevention

 Kameron Gifford, CPC

If you are practicing medicine today, you are at risk for allegations of fraud. What steps have you taken to minimize this risk? Does your clinic have a compliance plan? Does you compliance plan address coding and documentation risks and identify an actionable plan of oversight? When was the last time you had an independent review of your billing practices and office policies? What type of annual training is provided to your office staff and what type of assessments have been given?

If your practice can not answer these questions, you need to take action NOW.

Begin by creating a practical compliance plan. If you choose to buy a compliance plan off the shelf, remember this must be updated to reflect your office and your policies. Once you have a plan, use it. This is a common problem area for many practices.

Next review your clinic's billing policies and practices. If you don't have any, now is the time to create them. In the event of fraud allegations, this document proves your good intentions. Be sure to include specific steps to ensure compliance with local, state and federal regulations as well as contract level requirements

Plan an internal audit. Due diligence is your greatest ally in fraud prevention. If you are a physican who does their own coding or your office does not have a certified coder, I highly recommend an annual audit with a certified coder. The average primary care physican has a panel of 1200 patients. On average, the cost to audit 1% of your records annually would be $7,500. A small price to pay for peace of mind.

Educate everyone in your office.This is the single most important investment that you can make in your organization. Look for education providers that will come to your clinic and work to improve the entire team. A successful transition to ICD-10 will require extensive training and preparation. With the deadline less than a year away, what is your plan of action?

By following these simple steps, you will significantly reduce your chances of fraud allegations. ERM routinely works with physicians, clinics, hospitals and health plans to identify specific gaps in policies and practices, reduce error rates, and eliminate future defects. Don't wait until you recieve an audit notification. Act now.  

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