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The False Claims Act: 8 ways providers can avoid penalties and fines

By Prime Care Tech Marketing on Thu, Mar 03, 2016 @ 07:00 PM

iStock_000081024321_Small.jpgPeriodically, you will read about out-of-court settlements or court decisions rendered for False Claims Act violations. Claims may be subject to false claims accusations for treatments or services provided that are not deemed to be medically necessary, do not meet the coverage qualifications, or the medical record indicates they were not provided as ordered.

To take the side of an honest mistake, providers can find themselves inadvertently on the wrong side of the False Claims Act if medical record documentation does not support the following:

  • A medically necessary admission to a SNF within 30 days of a covered inpatient hospital stay lasting no less than three days,
  • That the resident/patient is receiving services and treatments for the condition or injury treated during the qualifying inpatient hospital stay,
  • The physician’s certification and subsequent recertification that the services ordered meet each of the qualifying requirements, and
  • The documentation identifies that the physician-ordered services were provided as ordered

Further, in an article written in April 2013, Amy E. McCracken wrote that providers must safeguard that claims filed do not include “worthless services” or “implied false certifications,” the two primary theories for the basis of liability. Worthless services suggests deficient services provided inconsistent with physician orders. Implied false certification infers the violation of Medicare or Medicaid regulations.

What are the potential damages? The False Claims Act provides for three times the actual damages and an $11,000 per-claim fine. This can add up quickly. In a recent McKnight’s article, a large provider agreed to pay $600K to resolve False Claims Act allegations. In this case, the facility in question failed to “provide patient care activities as recorded in the resident medical record of a patient and not providing certain care activities consistent with a physician order for more than a month.”

Also, in the case above, the provider has to “pay for a transition consultant to assist the new operator of the skilled nursing facility for a year. This consultant will help ‘identify risks and opportunities for improvement in providing skilled nursing services to residents at the facility.’”

What must providers do to minimize the risk of falling afoul of the False Claims Act?

  1. Confirm that the attending physician certifies and then appropriately recertifies the need for skilled care under the definition of skilled services within the SNF.
  2. Make sure the care plan is consistent with physician orders.
  3. Follow the care plan.
  4. Validate that the clinical documentation supports the services provided consistent with the care plan.
  5. Reconcile the clinical notes to make sure all disciplines, for example, nursing and rehabilitation, accurately and collaboratively support the resident’s/patient’s condition absent conflict or inconsistencies.
  6. Verify that the charges claimed are consistent with the documented physician-ordered services.
  7. Take advantage of the triple check process to confirm consistency of charges on the claim with the medical record, care plan, and physician orders. A mere typo can trip you up.
  8. Consider self-reporting. If you discover serious billing problems, voluntarily reporting the violation within 30 days of discovery may reduce and damages and penalties significantly.

Violating the False Claims Act carries with it heavy penalties to your hard-fought-for reputation and your finances. Take appropriate steps to minimize the risks. To do nothing would be cents-less.

Topics: False Claims Act medically necessary admission care plan physician-ordered services qualifying inpatient hospital stay certifications and recertifications penalties and fines


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