Switch to ADA Accessible Theme
Close Menu

Ways Healthcare Organizations Can Prevent and Detect Healthcare Fraud

Compliance rules and law regulation policy concept on virtual screen.

The healthcare industry is subject to myriad laws and regulations and is under the purview of an alphabet soup of regulators. One of the reasons for such heavy regulation is the prevalence of fraud across the industry. Healthcare practices looking to protect their practices and avoid instances of fraud must take affirmative steps to prevent fraud from happening, detect fraud when it does occur, and have a system in place to deal with fraudulent conduct when it is uncovered. Read on for tips on how to detect and prevent healthcare fraud in your healthcare organization, and if you have questions about a matter of healthcare law, reach out to a dedicated California healthcare law and compliance attorney.

Know Your Healthcare Laws and Regulations

Healthcare is governed by a wide range of federal and state laws and regulations. Many rules are updated and modified regularly to keep up with new practices. It is important for all owners, officers, staff, and physicians to know the rules and their respective responsibilities. Consult with knowledgeable healthcare attorneys to create reference guides concerning the various healthcare laws and regulations.

Broadly, healthcare providers should know their responsibilities and liabilities concerning the federal False Claims Act, Anti-Kickback laws, and Physician Self-Referral laws. They must also understand the elements and penalties for violating federal and state laws, including healthcare fraud, insurance fraud, Medicare fraud, and Medi-Cal fraud.

Ensure Accurate Billing

One of the principal sources of healthcare fraud charges comes from unlawful billing practices. There should be standard billing practices in place, with clearly-defined rules, oversight and periodic auditing. Overbilling, submitting false claims, altering codes to more expensive treatments or providers, or any other sort of billing shenanigans should be rooted out and dealt with appropriately. Clear rules, training, oversight, and auditing will help prevent any mistakes or intentional fraudulent acts from occurring or going unnoticed.

Maintain Robust Compliance Plans

One of the most surefire ways to prevent fraud and detect it when it does arise is to create and implement a comprehensive compliance plan. In addition, the Affordable Care Act requires healthcare providers to maintain compliance plans. A strong compliance plan includes a number of components, including:

  • Standards for compliance and good practices
  • Measures for violation detection and response
  • Election of compliance officers
  • Ongoing training and education for officers, staff, and physicians
  • Regular internal monitoring and auditing of practices and compliance
  • Structured organizational communication
  • Established disciplinary guidelines, made known to all staff and physicians

Consult With Legal Professionals and Government Agencies

Whenever entering into any sort of questionable arrangement, healthcare providers should cover their bases by consulting with an attorney. If there are concerns about referrals or billing practices, for example, talk to a seasoned healthcare law attorney. Immediately cease any questionable behavior until a complete risk assessment has been conducted.

If there are broader questions about whether a proposed arrangement may be permissible, your organization and your attorney may even wish to seek guidance from a government regulator. While inviting additional government oversight is typically to be avoided, there might be circumstances under which a given regulation is unclear and an agency may be persuaded to provide guidance or even a rule change.

Trusted Advice and Experienced Representation for Your California Medical Practice

For assistance with matters of healthcare regulatory compliance, auditing, fraud defense, employment disputes, mergers and acquisitions, business disputes, licensing, or any other healthcare legal issue, contact the Law Offices of Art Kalantar in Los Angeles or California statewide at 310-773-0001.

Facebook Twitter LinkedIn