Three Fraud and Abuse Initiatives for Physicians to Watch

As efforts to combat fraud, waste, and abuse intensify, medical practices are facing more and more scrutiny.

“We know that the government is more than ever looking to crack down on improper payments and to eliminate fraud and abuse in government programs,” said attorney Amy Nordeng, counsel, MGMA Government Affairs. “This is for sure the busiest year in terms of compliance, and so I can only imagine what you are experiencing out there in practice.”

During her Tuesday session at MGMA12 in San Antonio, copresented with attorney Robert Saner, principal at Powers Pyles Sutter & Verville PC, Nordeng shared some of the most recent physician-related fraud and abuse initiatives that she said should be on the “radar” at medical practices:

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.

“It will impact all practices, and it’s important because the statute contains severe penalties under the False Claims Act ...” said Nordeng.  Essentially, if a provider fails to meet the 60-day deadline, the overpayment will be treated as a false claim.

Though this requirement was instituted when the healthcare reform law was passed, “There wasn’t a lot of guidance of how to implement it,” said Nordeng. Further guidance, however, did come out in 2012 in a proposed rule.

Included in that proposal is the requirement that providers report overpayments that occurred up to 10 years prior. The proposed rule also further defines what it means to identify an overpayment, stating 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.

“We are waiting for a final rule so we are in a little bit of limbo,” said Nordeng. Still, she noted, practices are on the hook for returning any identified overpayments now.

Medicare enrollment revalidation initiative. CMS is on a mission to revalidate nearly all Medicare enrolled physicians by March 2013, and physicians and practices need to be aware. “Essentially your physicians or providers will get a request from CMS to revalidate information that needs to be responded to within 60 days,” said Nordeng.

Though responding does not require strenuous effort on behalf of physicians, practices must ensure physicians respond to such requests in a timely fashion, she cautioned. Failure to respond within 60 days could result in loss of Medicare billing privileges.  

Sunshine Act. 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, beginning in 2013.

Payments that must be reported include those for speaking honoraria, gifts, and meals, said Nordeng. 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.

This rule is about “shining light on the relationship physicians have with drug and device manufacturers,” she said, noting that some elements within the act are concerning. “We continue to work on this issue and we’re waiting to see what the final rule has to say.”