Administration, Billing & Compliance

ADMINISTRATION, BILLING & COMPLIANCE EXPERTS

The United States spends nearly $4 trillion dollars on healthcare every year, and the amount continues to grow. While physician, surgeons, and other medical providers are the backbone of the healthcare system, healthcare as an industry is run by diverse corporate and administrative interests who are intimately involved with every aspect of billing, payment, and collection. While compliant oversight and administration are integral to the stability of the healthcare system, complex challenges arise when medical billing is not performed in a compliant manner, and implicated parties may be held civilly or even criminally liable.

At the corporate level, Hospital Administrators and other executives run healthcare systems such as hospitals, physician’s groups, skilled nursing facilities, and clinics. They employ certified billers and coders to invoice patients, insurers, and governmental entities in a manner compliant with industry standards and federal laws. Civil litigation arises when healthcare entities and private payers dispute billed charges for services rendered. Common allegations include improper CPT (Current Procedural Terminology) coding, unbundling (billing for multiple procedures typically covered by a single code), upcoding (billing at an unwarranted higher level), and outright fraud. State and federal entities can file both civil and criminal actions under False Claims Act (FCA) laws which prosecute healthcare providers and entities who defraud state-run medical programs or federal programs such as Medicare and Medicaid. Governmental investigations focus on the same allegations that are common to private civil litigation, though they tend to focus more heavily on “medical necessity,” the overarching requirement that billed medical services must be reasonable, appropriate, necessary, and based on applicable clinical standards of care. When rendered services are medically unnecessary, they may not be billed under any circumstance. The most fertile area for False Claims Act investigations focuses on coverage for hospital admission versus outpatient observation. Fraudulent misclassification can bring both civil and criminal charges, and whistleblowers are monetarily incentivized to file Qui Tam lawsuits to expose fraud and abuse.

Elite has extensive experience investigating claims on behalf of private healthcare entities, corporations, State Attorneys General, and the United States Department of Justice. Call today to work gain actionable insight from our our in-house Case Strategy Team and access to top-tier healthcare professionals, hospital administrators, and certified CPT coding experts.

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