Hospitals often, for a number of reasons, raise quick and unfair allegations against their nursing staff. How you respond and handle these allegations is important. Knowing the resources available and their limitations is also important if you find yourself being unfairly accused, as well as preserving future options with respect to your license and nursing career.
These days with the state of the economy as it is, it should come as no surprise that insurance companies and HMOs are being even more aggressive at auditing than they have traditionally been in the past and attempting to take back payments for services rendered from physicians and health care entities.
While the health care industry as a whole might be growing, the providers reimbursement that the provider gets to keep is shrinking. There are some tactics and approaches that can be used by a health care provider that can not only protect them from improper allegations of fraud and abuse made by an insurance company during an audit, but even help the provider increase revenues in their practice if there is no audit, since it can serve as a means to supervise their own practice policies and find any shortfalls in billing and coding that could be costing them money.
Management service organizations can raise red flags with investigators as they are often used by non-professionals as a means to improperly operate and control a medical practice. A management company or administrative services company providing only administrative services to a medical practice is permissible. However, due to the State Farm Mut. Auto Ins. Co. v Mellela, 4 NY3d 313  decision and increasing scrutiny, many management company operators engaging in improper practices, have created a negative reputation for an otherwise legitimate service, which in different formats is used by hospitals.
A management company and medical practice run the risk of getting into trouble if the management company does not charge flat fees for services rendered at fair market value. Based upon professional responsibility, a medical professional could potentially be exposed to sanctions, penalties and loss of license if the arrangement is a disguised fee splitting or kickback scheme. These allegations are often raised by an insurance company or government investigator if a management company and a medical practice have a set of contract fees which continually change.