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Be aware of fraud regulations or risk exposure to penalties

June 4, 2014
by Ron Rajecki
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Laura Ashpole

One strength of the behavioral health field is the great lengths to which providers will go to ensure that patients have access to medically necessary treatment. However, providers must be cautious about how they accept new clients and bill for the services provided to those clients in order to reduce the risk of suspected Medicare or Medicaid fraud.

The federal government and individual states have been increasing their focus on addressing fraud in healthcare in general, and in the behavioral health field in particular. In May, a Medicare Fraud Strike Force operation resulted in charges against 90 individuals, including 27 medical professionals, for their alleged participation in fraud schemes involving mental health and psychotherapy services, which amounted to approximately $260 million in Medicare false claims.

Laura E. Ashpole, J.D., an associate at the law firm Popovits and Robinson in Frankfort, Ill., advises providers to be familiar with the Medicare enrollment and claims submission requirements under federal law. The rules can be complex, so it’s important for providers to consult their legal teams on these issues.

“Many substance use disorder treatment providers do not see a great deal of Medicare patients and for that reason are not Medicare-certified or enrolled,” Ashpole told Behavioral Healthcare. “However, as implementation of the Medicare-Medicaid Alignment Initiative continues to ramp up in states, substance use disorder treatment providers are seeing more and more Medicare beneficiaries and dual-eligibles. They need to be aware of the regulatory issues associated with that and ensure that they are appropriately billing for services rendered.”

According to Ashpole, behavioral health providers are becoming more open about the issues they are facing in Medicare billing and reimbursement. This is positive progress, as states and the federal government need to know where the issues lie and where the systems break down. She also advises organizations to encourage their staff members to come forward with concerns about potential fraud and abuse within the organization so that deficiencies can be addressed immediately and resolved through self-disclosure, as appropriate.

“Organizations need to be receptive to staff concerns of this kind, particularly since front-office staff often know best how bills and claims are processed administratively by the organization,” she says.

Generally, behavioral health providers are used to seeing more fraud investigations on the Medicaid side, but it’s clear that the federal government is expanding the scope of its investigations into false billings—as evidenced by the recent activity of the Medicare Fraud Strike Force. Providers can also expect the federal government to focus more closely on fraud and abuse in federal healthcare programs as a result of the Affordable Care Act (ACA), which contains considerable anti-fraud measures.

She is seeing a clear push from the administration to focus in on these issues, particularly in specialties like behavioral health where officials haven’t paid much attention previously.

“There are serious risks and consequences of fraud,” she adds. “We’ve seen substance abuse treatment providers shut down, we’ve seen mental health providers owing the Centers for Medicare and Medicaid Services millions of dollars for false claims. But I think most behavioral health providers are keenly aware of the risks and consequences associated with federal health care program fraud and abuse, and are making efforts to stay on top of the changes being made in terms of how health care is delivered and paid for by Medicare, Medicaid, and private payers.”

Ashpole also says that behavioral health providers work in a particularly challenging regulatory environment. However, the good news is that they know what the issues are and they are asking all the right questions.

“It’s important for providers to continue to pose questions to their legal departments and their state regulators to ensure they are doing all they can to stay within the bounds of complicated federal reimbursement laws,” she says.

See the top most wanted fraud fugitives here.