Affordable Care Act Rules to Prevent Fraud: How Increased Vigilance Will Affect Your Practice

If you are wondering how the new healthcare law – the Affordable Care Act – will affect your practice, you are not alone. Providers across the country are trying to understand the implications that this new law will have on reimbursements and the practice of medicine.  Well, because the public is clamoring for my opinion on this matter, I will embark on a series of blog posts dedicated solely to the different provisions of the Affordable Care Act.  You’re welcome.

One of the most important features of the Affordable Care Act is the increased measures designed to weed out fraud and abuse in the healthcare system. Whatever your opinion on this new law is, we can all agree that prosecuting and preventing healthcare fraud is a noble goal. In keeping with the spirit of preventive care in the Affordable Care Act, the anti-fraud measures of the law focuses on the prevention of fraud by identifying and remedying the sources of abuse. We have yet to see the law in full action but a reading of the statute appears to combat fraud with a broad stroke.  For example, the law includes the following:

More detailed credentialing process- CMS will be scrutinizing Medicare, Medicaid and the new Children’s Health Insurance Program (“CHIP”) provider applications a little more closely to prevent fraud from even occurring. To this end, CMS states that certain types of providers (read- DMEs and “Pain Management”) will receive special attention.

New enrollment process for Medicaid and CHIP- Each individual State will be responsible for screening providers for enrollment in Medicaid and CHIP. The States will be on the lookout for providers who have been excluded from Medicare or another State’s Medicaid program. If this evidence is discovered, the provider will be barred from enrollment in Medicaid and CHIP in any State.

Temporary stop of enrollment if patterns of fraud are detected- Medicare will be borrowing new strategies from the credit card industry to identify patterns of fraud. If a pattern is discovered, all provider enrollment will be stopped until the fraud is remedied.  Providers can be affected due to their geographic location or type of practice.

Payments stopped during investigation–  If there is a “credible allegation of fraud”, CMS will stop all payments to a provider during the investigation process. The investigation process could take several months and would be a disaster for a practice alleged to have committed fraud.

Although these features of the new healthcare law are designed to prevent wide scale abuse of the healthcare system, they are broad and aggressive enough to potentially affect honest providers. Remember that laws are like cobwebs, which may catch small flies, but let wasps and hornets break through. Therefore, it is wise for your practice to understand these new anti-fraud countermeasures and how they could potentially affect your practice.

Brendan P. Harney, Associate General Counsel

Mr. Harney joined MTBC in 2010 as an Associate General Counsel. His practice mainly focuses on healthcare compliance regulations including HIPAA and state privacy laws.