Fraud and Abuse Update: Billing Schemes and Medicare Fraud and the OIG’s National Health Care Fraud Takedown

1066058_patrol_hat_too1In our Georgia business and healthcare law firm, we have noticed that cases involving Medicare fraud and billing compliance issues are published on virtually a daily basis, underscoring the critical need that physicians, nurses and other care providers and billing professionals exercise caution and vigilance in billing Medicare or other third party payers. For example, last week in Dallas, Texas, two physicians and three nurses were sentenced to prison for submitting fraudulent claims to Medicare through a home healthcare agency. The financial harm and potential billing fraud and serious “zero tolerance policy” of the Office of the Inspector and Federal Government for Medicare fraud has enhanced the financial and legal risks to healthcare providers and billing companies for all billing discrepancies. The OIG published its 2018 National Health Care Fraud Takedown providing the following statistics, which reflect law enforcement efforts to combat healthcare fraud and abuse:

  • More than 600 defendants nationally were charged with fraud and abuse offenses, of whom 165 are medical professionals
  • Fraud and abuse offenses resulted in $2 billion in losses to our nation’s healthcare programs
  • 32 physicians were charged for crimes in connection with prescribing and distributing opioids

Therefore, more than ever, accuracy in billing third party payors, Medicare in particular, is critical. Failure to be compliant can result in fraud investigations or even patient harm. What does this mean for practicing physicians? Physicians and other healthcare providers face a higher risk of being audited.

Here are a few tips and suggestions to follow, in order to help reduce the likelihood of an audit or law enforcement investigation:

  1. Conduct internal audits to stay aware of billing practices within your practice.
  2. Communicate effectively and regularly with your office staff regarding the importance of being meticulous in every way respecting billing. Let them know that accurate records and billing documentation is a requirement of their job.
  3. If you are being audited, do not modify records that have been requested as a part of the audit, and engage experienced professionals to protect your interests.
  4. Have written policies and procedures that govern all aspects of medical and billing records.
  5. If you receive a notice for an audit, immediately contact your attorney to determine best practices and next steps for responding, noting any deadlines reflected in the notice.

Inquiries from payers can result in investigations if not properly handled by the medical practice. By remaining aware of the current news regarding scenarios with flawed billing, and implementing effective practice policies, it’s possible to avoid a detrimental audit.

Hamil Little PC

We advise and represent hospitals, medical practices, physicians and other healthcare providers with respect to healthcare compliance issues. If you have questions about this post, contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email,

Disclaimer: Thoughts shared here do not constitute legal advice. Please consult with an attorney to discuss your legal issue.



Contact Information