Page 9 - SOUTH FLORIDA HOSPITAL NEWS JULY 2022

How to Detect Healthcare

Fraud Activities

There are many pitfalls in healthcare. Activities that
seem innocuous could be deemed fraudulent.
Healthcare employers and healthcare whistleblowers
should be on the lookout for the following types of
activities involving Medicare, Medicaid or insurance
compensation.
Paying for patient referrals: Companies and indi-
viduals that pay others to refer patients, such as insur-
ance brokers getting paid by healthcare providers, or a
lab or diagnostics business paying a physician to send
patients for testing, or certain physicians getting paid
more by a hospital because they refer them patients.
BY BEN ASSAD MIRZA, Electronic health record (EHR) fraud: Companies
ESQ., LLM, MPHA that gather and sell electronic health records systems
and services may face liability for downstream improp-
er storing and use of data. It requires having down-
stream agreements, even with affiliated and subsidiary companies. It also requires
maintaining systems that meet government certification standards. In addition,
providers and hospitals may face liability for fraudulently claiming EHR incentive
payments, or for submitting fraudulent bills based on EHR systems designed to
improperly increase reimbursements.
Billing under the wrong NPI number: Companies often do not pay attention to
the NPI numbers that the billing is being done under. It is quite often that a health-
care provider bills under person A, but in reality, person B performed the services.
That is improper billing.
Billing under Medicare Advantage Capitated Contracts when patient has not
been seen: Companies that intentionally enroll Medicare Advantage patients, and
then fail to bring the patient into the office for initial medical assessment or failing
to provide the patient access to medical care, and then billing for it. Sometimes
companies fall into billing for incarcerated patients, or patients who are out of the
designated service area or even outside the country. Not removing these patients
from the billing system could lead to fraud upon the government.
Billing for services that are not medically necessary: Medically unnecessary
services may include unnecessary inpatient admissions, advanced imaging, unnec-
essary tests or lab work, and other procedures. For example: the ordering of extra
services that were never necessary and unrelated to the actual real reason why the
patient came to see the physician.
Billing for unlicensed personnel: This may include services provided by individ-
uals who lack the skills or proper licenses, or services provided by trainees without
the required supervision. For example: if a physician has a technician perform the
services, and the business bills the insurance company as if the physician had per-
formed the service.
Billing for unauthorized locations: This may include services performed at a
facility that is inappropriate for that service, or a facility that is improperly staffed
or equipped for the procedure. Or for example, hospitals systems that bill for serv-
ices at the higher hospital rates, even though the services were provided outside of
the hospital.
If you would like to see additional examples of healthcare fraud and what to look-
out for, please visit https://www.mirzahealthlaw.com/examples-of-healthcare-fraud.
If you would like to find out more about what the rights, responsibilities and obli-
gations of a healthcare provider are when it comes to billing and compliance, our
firm has the knowledge, experience and the background to guide you through that
process.

If you have any questions, contact Ben Mirza, Mirza|Healthcare Law Partners,
at (954) 445-5503 or BAM@MirzaHealthLaw.com.

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