In a press release from the the Department of Health & Human Services regarding changes in healthcare last July the Obama administration announced a ground-breaking public-private partnership to prevent health care fraud:
“Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder today announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration’s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers….” (Click here to read the article).
In the last three years over $10.7 Billion have been recovered by current efforts. This staggering amount of money leads me to two questions.
- What is the cost of fraud prevention and detection?
- Are the rules too complex to be 100% compliant?
The cost of healthcare fraud is easy enough to find:  an estimated $60 Billion is lost every year by CMS to fraudulent charges. On average only $3.6 Billion is recovered each year.  After an extensive search I have concluded that, while the cost of not fighting fraud is prevalent everywhere, the cost of recovering the fraud is not. the new task force has an estimated starting budget of $311 Million. This estimate was unclear if it included the individual government agencies budget for this task.  What good is recovering $3.6 Billion if it costs you $3.7 billion to recover it.
The bigger question is YOUR ability to be compliant.  While talking with another healthcare blogger, I came to the conclusion that the current state of healthcare reimbursement compliance is very similar to a speed trap.  Much like a road where the speed limits constantly fluctuate, the rules for reimbursement change regularly.  What does the local police officer do on the road? He waits at a point that he knows is difficult to comply with and writes his tickets. I don’t feel that the policing bodies of this new partnership will behave any different.  They are going to work smart, not hard, to capture fraudulent charges.
As your physical therapy software and practice management solution bestPT works together with you to maintain a high level of compliance by tracking your un-billed visits, unsigned notes and the claims workbench to name just a few.  We have established over 300 data-scrubbing and validation points that your claims go through once you submit a claim to help you maintain a high level of compliance during your physical therapy billing process.
What do you think will be the “ticketing points” for this new task force? Durable Medical Equipment(DME), Emergency care, or something else?
It is each Medicare provider’s responsibility to read and fully understand the rules and regulations that have been established for their specialty in Local Coverage Determination (LCD’s) and other official communications. In the event of an audit or other review of your claims, it is prudent for a practice owner to expect that Medicare’s auditors will follow these policies to the letter; in every case.  The old adage “If you did not write it, you did not do it†clearly applies. Read more
