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6 Ways to Avoid Unintentional Medicare Fraud

Greg Freeman, January 30, 2014

Dagli cites these top six areas in which physicians can unwittingly stumble into Medicare fraud:

1. Billing with an expired license. If you are billing when your license is expired or your staff's license is expired, you could be charged with fraud even though you are providing the service. Treatment provided in any gap period between renewals or when a staff member did not realize his or her license had expired technically was not provided, Dagli explains.

"This is not theoretical. There are people who have been convicted, paid sanctions, or lost their license because they let their license lapse. It happens to pharmacists, nurses, doctors," he says. "There have been cases where a lapse of just a few days resulted in allegations of Medicare fraud."

In those cases the fraud charges are sometimes driven by the managed care company, which is always looking for opportunities to declare claims invalid and save a few dollars, Dagli says. Licenses are easily verified by payers and prosecutors find the prosecution of such cases to be a slam dunk, he says. No license means there was no treatment, which means the claim was fraudulent.

2. Not supervising closely enough. If you are not in the same building, or in the same room or available by phone in some cases, you are not supervising, and this could be fraud. Requirements for physician supervision of other providers, such as therapists, will vary, but it is important to know what is required and that "supervision" is not a general term. It has a specific meaning for some treatments that must be met and documented.

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