By Dhar Law, LLP

Physicians all over the country are raising concerns over a letter recently released by the United States Department of Justice (DOJ). In the letter the Justice Department announced its intent to make improper conduct and corporate crime top priorities in terms of investigations and prosecution. The DOJ said the nation depended on the active enforcement of the criminal and civil laws put in place to protect the country’s financial infrastructure and citizens.

For physicians, medical clinics and hospitals, this new focus on “white collar crime” sounds particularly ominous.

Complication of current issues

The shift in the Department of Justice’s priorities has many in the medical community nervous. Most hospitals are corporations, and even if a physician’s practice is not owned by the institution, they would still have to collaborate with the hospital at some point in terms of charges for in-house procedures, the supplies they order and use and the process by which things are coded and charged.

All of these things determine reimbursement rates for Medicare and Medicaid. Coding and patient billing have always been issues widely known to plague hospitals and private practices. However, now there is even more of a challenge for physicians, their team members and medical coders to contend with.

New methods of reimbursement

Passed into law by the U.S. Congress in 2015, the Medicare Access and CHIP Recogniion Act (MACRA) was created to establish new systems to reimburse doctors for the care they provide Medicare patients. The complete transition to MACRA is scheduled for 2019, however there are portions of the law which are already in practice, and more implementation of MACRA is expected to take place in 2017, and in subsequent years. Currently MACRA allows physicians to choose one of two tracks to follow to comply with all of the changes, however, physicians and medical facilities are already at odds with the law and its rollout. Hospitals and physician clinics are confused by the rules and may not even be aware whether they are breaking any new laws.

2,398 pages and no explanation

Many in the medical community don’t feel they have been given the necessary information they need to make the appropriate decisions regarding which MACRA tract would be best suited for their circumstances. Those who are responsible for rolling out the law will argue the information is available and has been since 2015. Even so, MACRA’s final rule is 2,398 pages of complicated verbiage, which many providers feel has not been adequately explained. In addition, there are hundreds of providers who have not even heard of the new set of regulations. Many physicians have opted to bring in a consulting firm or an attorney to get themselves and their teams educated on the regulations.

Meanwhile, the DOJ has announced they are cracking down on the type of corporate fraud that is often associated with illegal Medicare and Medicaid billing.

Charges and documentation

MACRA directly affects physicians, and other practitioners who work independently, and these professionals have cause to be concerned. There are requirements which must be met in order to be able to charge for certain types of office visits.

In addition, the documentation in each patient’s chart must reflect every detailed charge. Unintentional over-billing along with improper or missing CPT and ICD-10 codes have always been huge issues in medical facilities and practices.

Coding and the determination regarding what a patient is ultimately charged does not start and end with the physician; but it likely the physician and hospital administrator who will come under investigation for suspected fraud. With a heightened focus on corporate fraud and the desire to prosecute these types of cases more than ever before, the medical community feels like it is being singled out, and at a time when it is already going through such a huge transition.

Under investigation? Seek experienced federal criminal defense.

Corporate fraud cases are serious. Besides the fines and the restitution courts can impose, there is the possibility that practitioners could spend some time in prison; not necessarily for anything they did, but for something they are vicariously liable for.

Medical professionals in the Boston, Massachusetts, area who come under investigation for a MACRA violation should seek the advice of a federal criminal defense attorney. Any practitioner who suspect they may have some issues regarding reimbursement rate, or who may have received notification from the Department of Justice should not hesitate to call an attorney.