George Breen Quoted in "Audit Are More Likely Under Medicare Advantage" - Internal Medicine News

“There is more focus now (by CMS), both looking at the plan and looking at the provider as to whether or not there is accurate information being submitted,” said George B. Breen, a Washington-based health care attorney and chair of his firm’s National Health Care and Life Sciences Practice Steering Committee. “From the plan’s perspective, they have the obligation to make sure the money being spent is, in fact, consistent with the diagnosis being reported, and that they have looked to see whether or not the record by the physician supports the condition.”

Alleged coding errors found by health plans or CMS can result in a health provider being kicked out of the program or affect their payments from health plans. Inaccurate information that results in an overpayment by CMS can also lead to a False Claims Act (FCA) violation, said Mr. Breen, who defends health providers in billing, fraud, and FCA investigations.

“Even though the claim may not have been directly submitted to Medicare, but to the Medicare Advantage plan, the government can argue the provider either submitted a false claim or caused a false claim to be submitted,” he said.

Complete documentation and regular staff training is also essential, Mr. Breen added. Employees charged with coding or documentation duties should understand MA rules and regulations what information is required. If hit with a fraud or coding error accusation, doctors should be able to say that they made efforts to identify mistakes, he said.

“It’s not enough to say, ‘I made a mistake,’” he said. “You have to be able to say, ‘I looked for mistakes and tried to make sure we weren’t doing anything inappropriate.’ At the end of the day if you made a mistake, you have to demonstrate that you did something to prevent [such errors] in the first instance.”