The Fraud Spotlight series is a long-form examination of current fraud trends and investigative strategies from our team of retired OIG agents and expert fraud investigators. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

When determining if a practice should spend the time, effort, and expenses that are associated with a quality internal compliance program, consider the following situation one of Advize Health’s retired OIG Special Agents ran into:

A specialty practice had a “glitch” in their billing system. When a patient was treated as part of a motor vehicle or workman’s compensation claim, that claim was submitted to that area of coverage. Those claims are routinely denied, and providers are forced to go into arbitration to obtain payment. Under Medicare rules, a claim may be submitted for payment when that initial claim is denied. 

The caveat, however, is that when payment from the primary insurance is received, the provider of the services has to refund the Medicare payment. This is a slippery slope, and requires a strong internal auditing program, as well as a strong internal billing compliance protocol. In the case of the provider in question, there was no internal auditing and review function, and as you can imagine, double payments were received. Money was never returned to the Medicare program, and the OIG visited the practice. 

The practice had to hire an attorney, conduct an extensive internal investigation, and incur hefty costs associated with the legal fees, litigation support, internal reviews, etc. The matter was not of a high dollar amount, but the costs for entering into the civil settlement far exceeded the settlement itself. Again, as we have stated previously, a penny-wise, and a pound foolish. A good compliance program will not necessarily capture everything from a fraud, waste, and abuse perspective, and it certainly will not “bulletproof” a practice from an investigation. 

A few dollars spent on the front end will give a practice the ability to understand vulnerabilities, identify areas for improvement, ensure that all staff are “level set” and ensure that when something does happen, that compliance effort can be demonstrated to the inquiring entity; it does go a long way. We take steps to provide preventative maintenance in so many aspects of our lives: we go to the doctor for a physical, change the oil on our cars, etc., but medical practices routinely just take a willfully blind approach to their internal compliance measures. 

Need a compliance program to keep your practice operating at its best? We can help.

We have stated numerous times in our weekly blogs that it is not a matter of if you have never been audited or investigated, it is a matter of when. Stating that “[you] have always done it this way, and it has not been a problem,” is vastly different than having never been audited and it never being identified as a problem. 

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact our former OIG and Fraud Investigation team by emailing for more information on our Fraud Spotlight series.