Fraud and Abuse Compliance for Marketing

Elizabeth Hogue, Esq.

Fraud and abuse compliance is more critical than ever for all providers. There may be nothing that destroys the value of businesses more quickly or significantly than a fraud and abuse compliance problem.

Fraud and abuse compliance is more critical than ever for all providers. There may be nothing that destroys the value of businesses more quickly or significantly than a fraud and abuse compliance problem.

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the primary enforcer of fraud and abuse prohibitions, has stated that there are two major types of fraud and abuse compliance that must be addressed through ongoing evaluation processes: (1) submission of claims, and (2) standards and procedures reviews.

There is no doubt that getting the submission of claims right is key to running a healthcare company that provides quality of care and makes money. Submission of claims requires providers to conduct prebilling reviews and postbilling retrospective audits. The process of these reviews is relatively straightforward, although providers take a regular beating on issues of whether care provided was reasonable and necessary, whether patients are homebound, whether patients are terminally ill, etc.

Some providers, however, seem to have the perception that as long as they have the requirements of submission of claims down pat, then they have done everything “fraud and abuse compliance-wise” that needs to be done.

These providers are missing the proverbial boat in a big way! There is a whole other area of fraud and abuse compliance that is equally important, according to the OIG. That is, do providers’ standards and procedures measure up?

Here are some key areas related to standards and procedures that have been the focus of recent enforcement actions by the OIG and other fraud and abuse enforcers: continues on page 33

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