3 Compliance Areas Under Scrutiny
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Scrutiny of doctors by the government

3 Compliance Areas Under Scrutiny

As efforts to combat fraud, waste, and abuse intensify, the government is increasing its scrutiny of medical practices. This is a busy time for compliance and it will only get busier.

The government has put forth many initiatives to fight fraud and abuse. The following three initiatives for medical practices to watch for:Scrutiny of doctors by the government

1. Overpayments. The Affordable Care Act (ACA) contains a requirement that providers must report and return overpayments of Medicare and Medicaid funds within 60 days of identifying them. The statute contains severe penalties under the False Claims Act.  Essentially, if a provider fails to meet the 60-day deadline, the overpayments will be treated as a false claim.

Originally, when the healthcare reform law was passed there wasn’t a lot of guidance on how to implement it. However, more information came out in 2012 in a proposed rule. Part of that proposal is the requirement that providers report overpayments that occurred up to 10 years earlier. When is a provider deemed to have identified an overpayment? The proposed rule states that a provider is deemed to have identified an overpayment if it obtains actual knowledge of the existence of the overpayment, or acts in reckless disregard or deliberate ignorance of the existence of the overpayment.

Until the final rule is out, practices are responsible for returning any identified overpayments now.

2. Medicare enrollment revalidation initiative. CMS’ mission: Revalidate nearly all Medicare enrolled physicians by March 2013. Once providers receive a request from CMS to revalidate information, they have 60 days to respond. Failure to respond within 60 days could result in loss of Medicare billing privileges which means no payment from Medicare!

3. Sunshine Act. Beginning in 2013, the Physician Payments Sunshine Act requires pharmaceutical, medical device, and other supply manufacturers to report payments to physicians to CMS, and it also requires reporting of a physician’s (or his family member’s) ownership in drug and device manufacturers and group purchasing organizations.

Payments include gifts, meals, and for speaking honoraria. According to the proposed rule, manufacturers are required to report this information CMS and physicians have an opportunity to review the information before the information is made public.

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