Medicare Compliance
Medicare Compliance Lawyers Representing Healthcare Providers Nationwide
Contact Lynette directlyIf your practice or business bills Medicare for patient services, you need to prioritize Medicare compliance. Medicare-participating providers are subject to numerous rules and regulations, and non-compliance with any of these rules or regulations can have severe consequences. Along with liability for recoupments and fines, non-compliant providers can also face Medicare exclusion—and they can even face civil or criminal enforcement action in some cases.
At Oberheiden P.C., we help healthcare providers nationwide establish, maintain, and prove Medicare compliance. We have extensive experience in this area. Not only do we have experience advising providers, but several of our lawyers previously prosecuted Medicare fraud cases at the U.S. Department of Justice (DOJ). As a result, we are able to work with our clients to thoroughly assess their risks and needs, and we are able to help our clients implement effective Medicare compliance programs that help them avoid unnecessary consequences.
What Does it Take to Establish (and Maintain) Medicare Compliance?
Medicare compliance is a huge subject. There are several aspects to Medicare compliance, and there are several steps that healthcare providers must take to ensure that they are complying with all pertinent requirements. At Oberheiden P.C., we take a systematic approach that is designed to ensure our clients implement comprehensive policies and procedures that reflect all of the unique aspects of their practices and businesses.
How do we help healthcare providers establish (and maintain) Medicare compliance? Our systematic approach involves:
1. Conducting a Comprehensive Medicare Compliance Needs Assessment
The first step in our process is to conduct a comprehensive Medicare compliance needs assessment. Whether you are starting a new healthcare practice or business, you are currently using an off-the-shelf Medicare compliance product, or your Medicare compliance documentation is outdated, effectively managing compliance starts with understanding where your needs lie. To determine what we need to do in order to bring your practice or business into compliance, we will evaluate things like:
- Your practice’s or business’s Medicare compliance obligations (based on the specific items and/or services your practice or business provides)
- Your current Medicare compliance policies and procedures (if any)
- The efficacy of your current Medicare compliance program implementation (if any)
- The sufficiency of any recent auditing and enforcement efforts
- Your recent Medicare compliance documentation (if any)
If your practice or business is currently billing Medicare, we will also spot-check your billings. The lawyers in our Medicare compliance practice are well-versed in all aspects of Medicare billing, and we can quickly spot any billing issues that have the potential to cause problems in the event of an audit or investigation.
2. Developing Custom-Tailored Medicare Compliance Policies and Procedures
Once we have a clear understanding of your practice’s or business’s needs, we can then develop a custom-tailored Medicare compliance program. Our lawyers will draft policies and procedures that reflect—and address—your practice’s or business’s specific risks, and that are designed with practicality in mind. A Medicare compliance program is useless if it just sits on the shelf. At Oberheiden P.C., we work closely with our clients to ensure that they will be able to effectively implement the tools and resources we provide.
3. Conducting Medicare Compliance Training
A key aspect of Medicare compliance program implementation is compliance training. Along with developing all necessary policies and procedures, we also provide our clients with training resources—and we conduct training programs for our clients’ personnel when desired. As with all other aspects of Medicare compliance, compliance training programs must be custom-tailored. This means that they must be suited to the individuals who will be receiving the training.
Executives, physicians, pharmacists, nurses, billing administrators, and other personnel must be familiar with different aspects of Medicare compliance. Having worked with thousands of healthcare providers and businesses across the country, we know where and when issues tend to arise, and we structure our Medicare compliance training programs accordingly.
4. Assisting with the Implementation of Organizational and Operational Safeguards
Depending on what your practice or business currently has in place, effectively managing Medicare compliance going forward may involve implementing various new organizational and operational safeguards. This could involve everything from appointing a Chief Compliance Officer to adopting new coding software. Our lawyers can provide recommendations based on your practice’s or business’s size and resources, and we can assist with contract negotiations, training, and other implementation-related matters.
5. Advising on Internal Investigations, Discipline, and Other Enforcement Matters
When it comes to ongoing Medicare compliance management, healthcare providers and businesses must be prepared to conduct internal investigations when necessary, and they must have protocols in place for administering appropriate (and consistent) discipline. We assist our clients here as well—both with regard to putting the necessary protocols in place and with regard to enforcing their personnel’s compliance responsibilities.
6. Conducting Periodic Medicare Compliance Audits
While it is important to promptly investigate suspected Medicare compliance violations, it is equally important to proactively monitor for compliance. This involves conducting periodic Medicare compliance audits. We conduct these audits on behalf of our clients, as an unbiased assessment is critical, and fully assessing compliance requires a comprehensive understanding of the most up-to-date Medicare rules and regulations.
7. Fully Documenting Our Clients’ Medicare Compliance Efforts
Finally, in addition to developing written Medicare compliance policies and procedures, participating providers and businesses must also document their compliance efforts on an ongoing basis. In the event of an external audit or investigation, having this documentation on hand will be critical. We help our clients implement systems for effectively documenting compliance as a matter of course, and we assist our clients with choosing appropriate storage solutions and ensuring document retrievability as well.
Founder Attorney-at-Law Former DOJ Trial Attorney Partner Former U.S. Attorney Former U.S. Attorney Local Counsel Former U.S. Attorney Local Counsel Former Senior DOJ Trial Attorney Federal Appeals Attorney Former DOJ attorney Local Counsel Former Special Agent (DOJ) Former Special Agent (FBI & IRS-CI) Former Supervisory Special Agent (DOD-OIG) Former Supervisory Special Agent (FBI)Put our highly experienced team on your side
Dr. Nick Oberheiden
Lynette S. Byrd
Brian J. Kuester
Amanda Marshall
Joe Brown
John W. Sellers
Linda Julin McNamara
Aaron L. Wiley
Roger Bach
Chris J. Quick
Michael S. Koslow
Ray Yuen
10 Key Aspects of Medicare Compliance for Healthcare Providers
As we said in the introduction, healthcare providers and businesses must comply with numerous Medicare rules and regulations. When it comes to Medicare compliance, comprehensiveness is critical, as even a single failure or deficiency can trigger recoupment liability, prepayment review, and other adverse consequences. We help our clients consistently comply with all pertinent requirements—including the following 10 key aspects of Medicare compliance:
- Only billing for items and services that are covered under Medicare
- Only billing for items and services that qualify as “medically necessary” under the Medicare reimbursement guidelines
- Properly coding all covered and medically necessary items and services when billing Medicare
- Avoiding common coding pitfalls such as upcoding and unbundling
- Being sure not to double-bill Medicare and other payors
- Taking adequate steps to ensure patients’ Medicare eligibility
- Ensuring compliance with the current Medicare rules and regulations (these rules and regulations change frequently)
- Ensuring that billing personnel know not to try to “help” the company by falsely inflating Medicare billings
- Documenting all patient services to avoid allegations of “phantom billing”
- Maintaining adequate compliance and billing records to satisfy the Medicare recordkeeping requirements
FAQs: What Healthcare Providers Need to Know About Medicare Compliance
How Important is Medicare Compliance?
With the media regularly highlighting the billions of dollars in fraudulent Medicare spend each year, it might be easy to think that compliance isn’t a significant concern. But, while it is true that some providers get away with fraudulently billing Medicare, the DOJ and other federal authorities are aggressively targeting Medicare fraud. Improperly billing Medicare can have serious consequences (including criminal consequences in some cases), so healthcare providers need to prioritize Medicare compliance.
How Can Healthcare Providers Verify Medicare Compliance?
Verifying a healthcare provider’s Medicare compliance involves conducting an internal compliance assessment. At Oberheiden P.C., we rely on extensive experience to conduct these assessments for our clients. If you are concerned that your practice’s or business’s Medicare compliance program may be inadequate, we can tell you what you need to know, and we can help you efficiently address any compliance deficiencies.
What Are the Risks of Failing to Maintain Strict Medicare Compliance?
Healthcare providers and businesses that fail to maintain strict Medicare compliance can face recoupment liability, fines, exclusion, and other penalties. Medicare audits and investigations are becoming increasingly common, and these inquiries can have severe consequences for providers and businesses that are not able to affirmatively demonstrate compliance.
Can I Manage Medicare Compliance In-House?
We do not recommend that any healthcare providers or businesses try to manage Medicare compliance in-house. There is simply too much involved. Even minor oversights can be extremely costly; and, as a result, it is important that all Medicare-participating providers and businesses work with experienced compliance counsel.
What Are Some of the Most Common Medicare Compliance Mistakes?
Some of the most common Medicare compliance mistakes include coding errors, failing to maintain the documentation needed to substantiate reimbursement requests, and failing to monitor for compliance on an ongoing basis. But, there are many other Medicare compliance risks as well, and healthcare providers and businesses must address all of these risks in order to protect themselves effectively.
Speak with a Medicare Compliance Lawyer at Oberheiden P.C.
Do you have questions about Medicare compliance? If so, we invite you to get in touch. Please call 866-594-0602 or contact us online to schedule an appointment with a Medicare compliance lawyer at Oberheiden P.C.