The Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA) , enacted in 2010 and has been implemented with full force after recent Supreme Court’s affirmative decision.

Reading through the ACA, we will see the obvious focus on the effort to improve anti-fraud and abuse measures.  Inevitably, a medical provider’s concern is more about how these measures will eventually affect the enrollment process, claim and billing.

The main theme of the changes introduced by ACA is to improve anti-fraud and abuse measures by focusing more on “preventive measures” rather than tradition “pay-and-chase” model.

Some of the measures are:

1) In-depth screening process during enrollment for Medicare and Medicaid

For providers participating or enrolling in Medicare and Medicaid programs, a provider might have to go through self disclosure, mandatory licensure checks,  site visits from officials, criminal background checks and even fingerprinting for those high risk providers.

2) Categorized risk management

Certain programs, like home health services or durable medical equipment (DME), are treated as high-risk programs thus new controls are placed to ensure that only providers with good standing can provide these services.

3) Auditing supported by centralized data repository and data analytics

A central data bank that gathers all the claim data is set up to help government’s auditing effort.  In addition, computerized programs with sophisticated data analytic measures are being used to detect fraud and patterns of fraud.

4) Enhanced federal sentencing guideline

The federal sentencing guidelines for healthcare fraud offenses are being directed to increase by 20-50% for crimes that involve more than 1M in losses.

5) Higher Fine and suspension of the payment upon detection of fraud

For providers who have committed fraud, they will face stronger civil and monetary penalties including $50,000 for each false statement or misrepresentation of a material fact and $50,000 or triple the amount of the claim involved for providers who know of an overpayment but do not return it.  If a credible allegation of fraud has been made, HHS Secretary has the authroity to withhold the payment.

6) Time is of essence

The act requires that all fee-for-service claims need to be filed with in 12 months of providing the item or service under the timely filing requirement.  Providers must report and return Medicare and Medicaid overpayments with 60 days of identification or high fines will be imposed.

In general, ACA has imposed some additional requirements to a provider’s day to day practice.  Higher due diligence is needed to make sure your practice is compliant with all these new requirements.

If you have any questions regarding the ACA and the impact to your practice, please contact us to schedule a consultation.




One Response to “What providers need to know about Affordable Care Act”

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