Medicare and Medicaid Compliance

Why Do I Need a Compliance Program?

Health care providers who bill Medicare and/or Medicaid are required to provide comprehensive and compliant claims for all services rendered and supplies/pharmaceuticals used in the delivery of patient care. Penalties for non-compliant claims are significant, including possible criminal prosecution, and civil and administrative enforcement which can result in significant monetary fines and sanctions to exclude providers from treating Medicare and Medicaid patients.

With the trends toward lower reimbursement and stricter regulation, a claims/billing compliance program becomes an important survival tool for any medical practice. An effective compliance program demonstrates your practice’s good-faith effort to comply with the laws and is designed to help you identify and prevent erroneous and fraudulent claims, eliminate billing mistakes, and reduce the chance of audit. The Office of Inspector General (OIG) acknowledges solo and small group practices may not have sufficient resources to implement industry-leading practices. Nevertheless, the OIG requires such practices to address compliance in a proactive manner which ensures state and federal laws are followed.

Your compliance program does not have to be perfect, but it must be effective, and each practice has the burden of demonstrating its effectiveness to obtain the benefit of reduced culpability. Chapman Law Group’s legal expertise and industry partnerships make us an excellent provider of compliance services that are designed to find your claim weaknesses and correct them before Medicare/Medicaid discover the problems.

How We Can Help with Medicare and Medicaid Claims Compliance

Chapman Law Group is skilled at assisting clients with the “number one risk area” identified by the OIG, which is claims coding and billing. Chapman Law Group can help you with claims compliance by prospectively addressing billing issues, whether related to missing charges, unstated procedures, inaccurate and non-compliant charging, and National Correct Coding Initiatives (NCCI).

It is difficult to satisfy Medicare/Medicaid payer documentation and coding requirements necessary to receive appropriate payment. Therefore, medical practices should have a compliance program in place to identify problems and correct them before Medicare/Medicaid appear on the doorstep with a demand for repayment of overcharges. Even for small practices, the repayment amount demanded can exceed hundreds of thousands of dollars, not to mention fines, and potential criminal and civil penalties.

Chapman Law Group helps to make sure that medical practices, through appropriate coding and claims submissions, do not run afoul of the five main federal fraud and abuse laws:

  1. 1. False Claims Act,
  2. 2. Anti-Kickback Statute,
  3. 3. Stark Law,
  4. 4. Exclusion Statute, and
  5. 5. Civil Monetary Penalties Law.

Chapman Law Group will work with your office billing and coding staff to obtain copies of your claims and carefully inspect them using a proprietary system to identify problems.

Chapman Law Group collaborates with a well-respected coding specialist group that utilizes proprietary software and decades of industry experience to test the bulk of your claims for the following problems:

  1. billing for items or services not rendered or not provided as claimed;
  2. submitting claims for equipment, medical supplies and services that are not reasonable and necessary;
  3. double-billing, resulting in duplicate payment;
  4. billing for non-covered services as if covered;
  5. misusing provider identification numbers, which results in improper billing;
  6. unbundling (billing for each component of the service instead of billing or using an all-inclusive code);
  7. failure to properly use coding modifiers;
  8. clustering; and
  9. upcoding the level of service provided.

How Do I Comply?

Chapman Law Group’s analysis of your charges/claims will pinpoint erroneous charges and identify whether non-compliant charging practices exist. Because of this rigorous process, we can review documentation relative to charges posted, provide real-time feedback to clinical staff, and work to correct documentation. Chapman Law Group regularly advises doctors, pharmacists, dentists, and other practitioners who are subject to claims audits by Medicare/Medicaid.

Chapman Law Group is dedicated to defending licenses and livelihood of all health care professionals: Doctors, Physician Assistants, Nurse Practitioners, Nurses, Medical Assistant. If your professional practice is in jeopardy due to problems related to claims submission, you should contact Chapman Law Group and seek assistance from their highly qualified health law attorneys.


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