Billions of dollars are lost from Medicare each year due to fraud, waste and abuse, and the government expects you as a doctor or Medicare provider to serve a “gatekeeper” role to protect Medicare funds.  As a result, you should be careful to avoid being used or manipulated in ways that hurt Medicare and that could lead to you facing potential criminal, civil, or administrative penalties, including even prison.

I have prosecuted health care fraud cases for the federal government, and I have also defended people who were accused of fraud.  Because of my experience on both sides of health care fraud cases, I want to share a few key things to help keep you out of trouble.

Three points on the medical side:

• Be careful about taking jobs that involve a type of medicine that you do not regularly practice in.  Home health, hospice, durable medical equipment, genetic tests – Medicare has specific requirements for these services, and you should not order these services unless you know those requirements.  For example, you should not order home health services unless you know Medicare’s definition of “confined to the home.”

• Be careful about taking jobs that involve “chart review” without direct patient contact.  If you have not seen a patient or talked with the patient, then you probably should not be signing orders relating to those patients, especially if you are not planning to do any follow up yourself.

• Be careful anytime someone tells you that Medicare “wants” you to do something.  Medicare typically does not pay for preventative services and does not tell doctors how to practice.  If someone is telling you that Medicare wants you to do something a specific way, this could be a red flag.

Three points on the financial side:

• Be careful about taking jobs that pay you on a per-chart or per-patient basis.  This is a common red flag for fraud, and the government may view this as a violation of the Anti-Kickback Statute.  You generally should be paid only for the specific services that you do and that are covered by billing codes and Medicare rules.

• Be careful when you assign your billing rights to an employer.  If you do this, you should regularly get information about what has been billed in your name to make sure that your employer is not billing services that you did not actually do, and you should pay attention to services that are resulting in large amounts of payments.

• Be careful if your employer waives co-payments.  Medicare requires providers to make reasonable efforts to collect co-payments, and the routine waiver of co-payments can be a red flag of fraud because fraudsters often make more money by getting patients to not look at their explanation of benefits forms than they would by collecting the copayments listed on those forms.

Two more things that you should be aware of in terms of how the federal government investigates fraud, waste, and abuse.

First, billing data says a lot about your practice, and you should know what your data looks like to the government.  Every time you order home health, hospice, durable medical equipment, medications, tests, or services for a Medicare patient, someone is going to bill Medicare and identify you as the provider who placed that order.  Those orders can add up to huge amounts of money if you are not careful.

Second, if federal agents come talk to you, you should take it seriously, but you don’t have to talk with them right then and there.  Even if you’ve done nothing wrong, you may say something by mistake that might get you in trouble, or there may be a disagreement later about what you said.  You can invoke your right to counsel and ask to schedule an interview for a later time when you can be better prepared and not caught off-guard.

I hope that these tips help you stay out of trouble.  Thanks for watching, and thanks for all that you do for your patients!