Fraud & Abuse

The Challenge:
CMS has insured compliance with very stringent billing guidelines with the passage of the False Claims Act.  Failure to fully comply brings some very strong penalties, including stiff fines and even jail terms.  The Department of Justice (DOJ) acts as sheriff in making sure everyone plays by the rules and these are folks you definitely do not want knocking on your door.

The most notable rule is commonly called the "72 Hour Rule".  Under this mandate, hospitals are required to combine outpatient facility charges with inpatient charges that occur within a 24-hour window of admission.  This is intended to insure that the DRG-based payment pays for all the charges associated with a single incidence of care.  Most billing systems have a mechanism to prevent split billings from occurring, but invariably, these mechanisms sometimes fail.  The result can lead to a $10,000 fine per occurrence and frequent abuse can even lead to jail time.  Some hospitals have faced hundreds of thousands of dollars in fines and penalties for failing to adhere to this billing requirement.

In addition, many private payors have joined in this policy with contract language requiring the bundling of inpatient and outpatient charges rendered within a given window of time, usually 3 days.

We have yet to find a billing process that is 100% fool-proof in preventing violations of the 72 Hour Rule.

The Solution:
The Harvest Fraud & Abuse tools monitor violations of the 72 Hour Rule as well as the Medicare 24 Hour Re-Admission policy.  This tool provides you with an acceptable post-submission testing process provided by the Safe Harbor provisions of the False Claims Act.  By finding slip-ups right away, you can avoid costly fines and penalties by notifying your Intermediary of the error and correcting it.  And let's not forgot those other payors who might decide to audit your billing, just looking for these types of problems as well.  You certainly don't need a huge payback for failing to adhere to the billing requirements of your contract.

Avoid Fines and Paybacks:

• Detect separate inpatient and outpatient bills for the same incidence of care.
• Investigate inpatient bills for discharges and re-admissions within 24 hours for the same diagnosis.