Compliance, Fraud, Waste and Abuse | ArchCare
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Compliance, Fraud, Waste and Abuse

ArchCare takes the detection and prevention of fraud, waste and abuse very seriously. We understand the negative impact these abuses can have on individual health plan members, the Medicare and Medicaid programs, providers, and their business associates. The federal government has strict guidelines for all healthcare companies to follow, which will assist in avoiding fraud, waste and abuse in the healthcare industry.


At ArchCare, we adhere to all the regulations set forth to help protect our members and providers. All documentation for our Medicare beneficiaries and Medicaid members is approved by CMS before its distribution to ensure we are compliant with current rules and aiding our members to the best of our ability.


The government defines fraud, waste and abuse as:

“Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representation, or promises, any of the money or property owned by or under the custody of any healthcare benefit program. Failure to comply with the requirements of CMS programs that may result, directly or indirectly, in unnecessary costs to the Medicare or Medicaid program or improper payment for services that fail to meet professionally recognized standards of care or are medically unnecessary.”


It is important to train your staff to correctly describe services offered with the proper revenue and procedure codes, so they don’t claim more than what was performed. This will avoid problems with unwanted upcoding. It is essential to make them aware of codes that consolidate services and the necessity of applying them instead of a series of codes for the same services. This will avoid claims made that exploit service charges or result in unbundling.


Careless duplicate billing for the same service, billing for services not rendered, billing for unauthorized services and misrepresenting medically necessary screening and noncovered services with the wrong codes can cause tremendous problems for providers and medical facilities. Signing blank records or certification forms and sending bills to post office box locations can also create administrative disasters.


Providers should be aware that they can be held responsible for abuses and fraudulent claims reported by other offices or laboratories if they are listed as the referring physician. Be sure to use reputable labs and specialists when referring your patients for further testing or medical assistance.


Penalties for fraud and abuse can be civil as well as criminal. It is up to the U.S. Attorney’s Office to decide which of the two means will better serve the interests of the Medicare or Medicaid program. Individuals or entities involved in civil suits can face fines and/or repayment of damages up to three times the amount if found to have violated program regulations. In extreme cases of abuse, those involved in fraud will be prosecuted by the U.S. Attorney’s Office and may be subject to significant fines, penalties, restitution, and in some cases, imprisonment.


To help the federal government prevent fraud, waste and abuse, ArchCare educates its plan members on how to identify and report signs of health insurance, Medicare and Medicaid fraud. In cooperation with CMS, the New York State Department of Health and the Office of the Inspector General, we have developed systems and established policies and procedures for our highly trained staff to follow to help detect and prevent abuses. These procedures keep us in compliance with federal regulations and permit us to assist and protect our members and providers.




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