What Internal Medicine Doctors Need to Know About Healthcare Fraud

Internal Medicine Practices: Prime Targets for Government Investigations

If you have a successful internal medicine practice, you can easily become a target for government investigation. Internal medicine specialists are prime target for federal fraud investigations, Medicare billing extrapolations, and invasive ZPIC audits. Computer programs are designed to identify doctors to target by comparing doctors in similar specialties or geographic areas, which is a suspect method at best.

Because of these computer programs, internal medicine doctors in numerous states are being accused of healthcare fraud. Even the accusation alone puts them at risk of losing their reputation, license, and careers. Prosecution areas include:

• Opioid Investigations
• Fraudulent Home Healthcare Certifications (Form 485)
• Medicare Billing Fraud
• ZPIC Audits
• Billing for Medically Unnecessary Services

If your practice is being audited by the Centers for Medicare and Medicaid (CMS) or a commercial insurance plan, or if you’re notified of a patient complaint regarding prescriptions of controlled prescriptions, or if you’re concerned about any other potential investigation against your practice, get help right away. If you wait to contact an experienced attorney, it becomes harder to defend and protect your interests.

The U.S. Justice Department has increased the scope and level of scrutiny regarding internal medicine specialists. Prosecutors investigate doctors for a variety of services, most often when those services are outside the doctor’s core practice. One example is that many internal medicine specialists serve hospice and home healthcare agencies, both of which are areas with rampant Medicare fraud issues. Doctors can get into legal problems by certifying, or recertifying, Medicare Form 485 if the government rules the patient wasn’t sufficiently examined or didn’t qualify for the certified services. Federal investigators and prosecutors have also increased their review of opioid prescriptions in internal medicine practices. The FBI and the DEA have arrested numerous internal medicine physicians in all states, charging that they violated the Controlled Substances Act by over-prescribing levels of opioids.

Our healthcare fraud and audit defense lawyers help you avoid criminal prosecution and license issues in extremely complex situations. Some examples include extremely high error rates, missing charts and notes, medically unnecessary procedures, billing for services not provided, and accusations of upcoding.

The sooner you contact an attorney when you’re being audited or investigated, the better your chances of concluding the audit without escalation. You’ll save considerable time, effort, and money by hiring experienced counsel right away.

CMS Audits and Investigations

CMS is the largest healthcare payer in the United States, and they are required by law to protect the Medicare Trust Fund. Every year, medical claims errors cost the agency tens of billions of dollars in inappropriate payments. To prevent these inappropriate payments for harming the Medicare Trust Fund, the CMS works with contractors and intermediaries to audit these claims. Examples of these relationships include:

• Recovery Audit Contractor (RAC): RACs review claims post-payment with the goal of recovery inappropriate payments. RACs also notify CMS of any identified errors to help CMS prevent future inappropriate payments. RACs receive a percentage of the money they recover for CMS, which gives them the incentive to investigate aggressively. It also increases the likelihood that a provider will be involved with a RAC audit. These audits can trace back three years of past payments.
• Supplemental Medical Review Contractor (SMRC): The SMRC is a national program intended to reduce improper payments by providing medical reviews for Medicare Part A, Medicare Part B, and Medicare DME claims. These audits are directed by CMS, and CMS determines the issues, scopes, and time frames for the audit.
• Unified Program Integrity Contractors (UPIC): UPICs perform regional investigations to identify and prevent fraud, waste, and abuse for Home Health and Hospice (HH+H), Medicare Part A and Part B, Medicaid, DME, and Medicare-Medicaid data match program.
• Investigations Medicare Drug Integrity Contractor (I-MEDIC): IMEDIC is designed to monitor any fraud, waste, and abuse initiatives for the Part C (Medicare Advantage) and Part D (Prescription Drug Plan) benefits.
• Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC): PPI MEDIC provides prepayment data analysis, audits, and risk assessments for Part C and Part D plans. They also provide plan sponsor outreach and education.

As you can see, there any many programs and agencies designed to work against. Don’t stand alone in an audit: contact an attorney who specializes in healthcare fraud and audit defense today.