It’s Corporate Compliance Week! Revenue cycle compliance: Fraud and abuse

When you think of “compliance,” HIPAA privacy and security usually come to mind.

But health care compliance first arose in the 1990s with Revenue Cycle compliance. Health care providers face enormous financial pressures, and Michigan Medicine is no exception. However, faculty and staff must never lose sight of their obligation to accurately document the services provided and conduct financial transactions — including coding, billing, reimbursement and referrals — in a legal and ethical manner.

Examples of fraud and abuse include incomplete or inaccurate documentation, altering documents to gain higher payment, misrepresenting dates and descriptions of services, and not providing patients with notice about appropriate payment responsibilities or appeal rights.

Such violations of state and federal fraud and abuse statutes carry harsh legal consequences, including the potential for heavy fines and exclusion from the Medicare program.

There are other serious consequences beyond fines and penalties, though, including reputational harm to U-M, Michigan Medicine and its providers. More importantly, Revenue Cycle compliance directly affects quality of care and patient safety and satisfaction. Inaccurate documentation can cause medical errors and misunderstanding of payment obligations, ultimately leading to patient dissatisfaction, concerns about questionable ethical practices and potential loss of trust.

Remember, compliance — including Revenue Cycle compliance — is above all a quality of care issue.