BUSINESS INTEGRITY PROGRAM
Policy Manual
APPROVED: May 14, 1998
by BOARD OF DIRECTORS
WASHINGTON COUNTY HEALTH SYSTEM
formerly titled “Legal Compliance Program”
Revised 9/2000
3. Billing and Claims
Washington County Health System must be careful to submit correct bills to patients, insurers, and the state and federal healthcare programs. Diligence, care, and integrity are all responsibilities of healthcare providers who are allowed to bill Medicare and Medicaid. Since the Health System has been given the right to bill government-funded programs, this responsibility cannot be abused. The Health System is committed to always submitting accurate claims. Many staff are responsible for entering charges or procedure codes. Each employee is expected to perform their jobs in accordance with billing rules. If inaccurate or questionable claims are suspected, an employee should immediately discuss it with their supervisor or the Director of Business Integrity.
False billing is a serious offense. Medicare and Medicaid laws specifically prohibit any false statements or claims regarding claims for healthcare benefits. It is also unlawful to fail to report a mistake that causes the Health System to collect funds that it is not allowed to collect. Examples of false claims include:
Ø Billing for services not provided
Ø Filing duplicate claims
Ø “Upcoding” for more expensive, complex services than actually provided
Ø Misstating costs on a hospital cost report
Ø Falsely indicating that a healthcare professional performed services
Ø Charging for unnecessary hospital days
Ø Billing for medically unnecessary services or supplies
Ø Billing excessive charges
Any Health System employees involved in billing claims should watch for these and other errors. Even outside consultants who advise the System are required to follow the laws. Medicaid law also prohibits the System from charging rates higher than the State allows, and no Medicaid patient may be asked to pay a fee as a condition for treatment by the Health System.
The Health System follows strict Medicare laws on who may bill for professional services. This process is called “re-assignment”. If there is a question about whether the Health System may bill for physician fees, the Director of Business Integrity should be contacted. The Health System may not submit claims for other organizations unless these laws have been followed. The Health System also cannot submit bills prepared by other companies without an approved contract. The Director of Business Integrity will review such contracts.
If the Health System were found to violate the false claims rules, the penalties are severe. The crime is a felony, and fines of $25,000 per offense, prison terms of up to five years, or both, may be imposed. Individuals found guilty of filing false claims can be fined up to $10,000 per offense and jailed for up to one year, or both. These are criminal penalties, and civil penalties may also apply. The civil penalties may be fines up to $10,000 for each false claims, as well as repayment of up to three times the amount billed. The person or the Health System may also be excluded from Medicare and Medicaid. If the Health System were to bill for professional services without proper re-assignment documents, the fines may be $2,000 per claims and up to 6 months in prison, or both.
The State of Maryland also has similar laws that may apply.
Other laws regulate the Health System:
Making false statements about Medicare certification is a felony, and can result in fines up to $25,000, five years in prison, or both. If a crime related to Medicare or Medicare fraud or patient abuse is committed, the Health System and the individual providers can be excluded from federal healthcare programs for at least five years. If the Health System or any provider is convicted or fraud, theft, embezzlement, or other financial misconduct, the exclusion may be indefinite. All employees, contractors, physicians, and vendors will be screened to make sure that they have no convictions on their record.
Any false statement to the government is illegal. This includes statements on Medicare or Medicaid claim forms. It is also illegal to use the U.S. Mail or computer or phone transmissions to defraud the government. If two or more people submit false claims together, they may be found guilty of conspiracy to defraud the government.
Washington County Health System has a firm policy of high ethics, integrity and accuracy in all its financial dealings. All staff (and outside consultants) involved in entering charges, preparing bills, and documenting services must maintain these high standards. Full compliance with all relevant laws is required of all Health System staff.