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Health care fraud case underscores the importance of paperwork

The number of Americans enrolled in a Medicare Advantage plan is skyrocketing. Statistics show enrollment has nearly doubled over the past 10 years, and Medicare Advantage now comprises about 22 million people. That’s one-third of all Medicare beneficiaries.

This rise in popularity has also invited more scrutiny. A number of health care companies engaged in the Medicare Advantage business have faced accusations of fraudulent billing. One ongoing case is a good reminder that the best defense against these accusations is thorough recordkeeping.

Unsupported diagnosis codes

A story from Kaiser Health News and NPR focuses on the health care company Essence Group Holdings Corp. According to the report, Essence is facing fraud questions from multiple sides: two audits from federal agencies and a whistleblower lawsuit. Many of the allegations center around diagnosis codes.

For example, the audit by the Department of Health and Human Services Office of Inspector General pored over 218 diagnosis codes Essence submitted to the Centers for Medicare & Medicaid Services. Auditors determined that one-third of those diagnosis codes “either were not supported in the medical records or could not be supported because Essence could not locate the medical records.”

Essence denied any wrongdoing and agreed to pay a nearly $160,000 refund in connection with that audit.

Documentation is key

Essence is not the only Medicare Advantage organization facing extra scrutiny. Even the industry’s biggest companies are fending off these types of accusations. It’s clear the current climate when it comes to Medicare Advantage diagnosis codes is one of doubt and skepticism.

This is why it is often so important to have proper documentation. If a health care company can respond to any doubts with clear paperwork, explaining not only why they made the decision but offering the evidence to support that choice, it can potentially defuse any federal suspicion before it snowballs.

That doesn’t guarantee a health care company won’t be bothered. Sometimes federal agencies decide to throw tremendous resources behind pursuing a health care fraud case. In these circumstances, proper documentation combined with a strong attorney can help form a solid defense.

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