Errors in the medical field are costly. This includes errors in billing, errors in receivables, errors in grant funding and more. Because money is always an issue in the medical field, you may have heard that numerous clinics and other operations occasionally use Medicare fraud and scamming to get kickbacks from the government. This includes fraud in billing for not only procedures and appointments, but equipment as well. Studies show that Medicare fraud has resulted in billions of dollars of loss, which is a shame for the people within the Medicare system who could have truly used the funds to their benefit.
Medicare fraud is a dangerous spiral and if and when a clinic or organization is caught, the financial and societal repercussions can be absolutely devastating. After the introduction of the Affordable Care Act (or the ACA) in 2009, the government cracked down specifically on fraud within the healthcare system. Penalties were heightened and more strict guidelines were put into place. For example, for losses of more than a million dollars, federal sentencing guidelines increased up to 50 percent. That means that the maximum penalties available for people who commit fraud crimes are significantly higher than they used to be.
There is also significantly more oversight on companies that have had issues with fraud in the past or pose a specific threat of fraud to the system. This is figured out through advanced modeling technology which uses predictive coding to determine what kinds of organizations are more likely to be involved in fraud. Not all of this can be done through technology however, because technology can miss many elements of human error. It is important to also have a human eye on fraud because humans can use deductive reasoning to examine the situation and detect deception in a different way.
A large part of this crackdown comes from nurse audit reviews, which are designed to provide a thorough look into every claim filed by a clinic to ensure they are necessary and correct. During these reviews, specialists will review all records in a patient’s file to ensure that any kind of treatment or procedure suggested by a doctor is both necessary and fitting with the patient’s medical history. This is where the human element is especially helpful because humans are more likely to catch deception from a narrative perspective rather than solely through numbers. Nurse Medicare audits will also work to make sure that any procedures that are recorded as having occurred, actually did occur. This requires a lot of coordination and corroboration on the part of the reviewers, who rely on impeccable record management systems to ensure the information they are getting is accurate and complete.
Overall, if an individual is found to have committed Medicare fraud, they may be fined as much as $250,000 per offense. Organizations that commit fraud may be fined as much as $500,000 per offense. If an organization has a long history of fraud, it is likely these fines will far outweigh the kickbacks they received through the fraud. Nurse audit reviews are an excellent way to ensure accountability and transparency in both organizations and individuals.