7 insights into healthcare fraud investigations

Healthcare organizations must implement solid compliance programs if they want to avoid healthcare fraud charges. RevCycle Intelligence investigates what actually happens during a healthcare fraud investigation.

Here are seven insights:

1. In a healthcare fraud case, the prosecutor looks into why a healthcare organization's compliance program did not stop the fraud from occurring.

2. Prosecution will dive into the compliance program's design and structure as well as if it was labeled as a "paper compliance program or a real compliance program," according to RevCycle Intelligence.

3. In essence, healthcare prosecutors decide whether an organization executed an impact compliance program, or if they were doing the bare minimum to meet requirements.

4. "Real" compliance programs will include a compliance officer who ensures the organization is acting legally and ethically.

5. A prosecutor's assessment of an organization's compliance program's robustness will influence whether a criminal charge will be brought against the organization. That is, did the organization set up a program to effectively catch and stop potential healthcare fraud?

6. In addition to deciding whether to bring a case against the company, the government must also decide whether to mandate the organization implement monitors to stop potential healthcare fraud.

7. Ultimately, healthcare organizations should continuously monitor their compliance programs, to avoid potential criminal charges brought by healthcare fraud.

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