Fraud%20and%20Abuse

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Fraud and Abuse
Steven M. Verno, CMBS, CMSCS, CEMCS, CPM-MCS
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Disclaimer
I am NOT a lawyer. This presentation contains NO
legal advice. This presentation is for training
purposes only! Images included were obtained from
free public domain websites
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News!

• Broken Arrow Doctor Claiming To Cure Cancer Fined
  2.5 Million For Fraud
• (Source Oklahoma Channel 6 News)
• Hospital group fined 3.8M for alleged Medicare,
  Medicaid fraud (Source Fierce healthcare)
• Indo-American Doctor Fined 43 Million, Jailed
  For Fraud (Source The LINK)
• Doctor Fined 21 Million For Fraud
• (Source Daily Press)

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What is Fraud?

• Fraud occurs when someone knowingly lies to
  obtain some benefit or advantage to which they
  are not otherwise entitled or someone knowingly
  denies some benefit that is due and to which
  someone is entitled. (Reference California
  Department of Insurance)

Under HIPAA, fraud is defined as knowingly, and
willfully executes or attempts to execute a
schemeto defraud any healthcare benefit program
or to obtain by means of false or fraudulent
pretenses, representations, or promises any of
the money or property owned byany healthcare
benefit program.
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Examples of Fraud

• A healthcare provider bills for services the
  patient never received.
• A medical supply supplier bills for equipment the
  patient never received.
• Using another persons insurance card to get
  medical care, supplies, or equipment.
• Unbundling Services (Modifier 59)
• Upcoding/downcoding a visit.
• Misrepresenting the diagnosis to justify the
  service
• Misrepresenting the type or place of service
• or who rendered the service

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What is abuse?

• Abuse occurs when doctors or suppliers dont
  follow good medical practices, resulting in
  improper payment, or services that arent
  medically necessary.

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Examples of Abuse

• Excessive charges for services or supplies
• Claims for services not medically necessary or,
  if medically necessary, not to the extent
  rendered
• Breeches of assignment agreements
• Improper billing practices
• Billing Medicare as Primary when Medicare is
  Secondary
• Billing Medicare more than other insurance
  companies.
• Routine waivers of patient copayments and
  deductibles

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Laws (State and Federal)

• False Claims Act (FCA), 31 U.S.C., s. 3729
• Florida False Claims Act, F.S. 817.234
• Anti-Kickback Statute 42 U.S.C. s. 1320a-7b(b)
• Physician Self-Referral (Stark) Statute, 42
  U.S.C. 1395nn
• Deficit Reduction Act of 2005
• HIPAA, Title 18, Section 1347
• Fraud Enforcement and Recovery Act of 2009

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PENALTIES

• Up to 5 years in prison
• Fines of 10,000 for each false claim
• Recovery of the costs of litigation.
• Triple damages
• Mandatory exclusion from the Medicare and
  Medicaid programs for 5 years
• Loss of Medical License

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Suspicious Activities

• Do not collect mandatory copayments or
  coinsurance (Insurance Only)
• Advertise free consultations to people with
  Medicare.
• Claim they represent Medicare or a branch of the
  Federal Government.
• Use pressure or scare tactics to sell you
  high-priced medical services or diagnostic tests.
• Bill Medicare or another insurer for services or
  items you did not get.
• Bill Medicare for services or equipment that are
  different from what you received.
• Bill Medicare for home medical equipment after
  you returned it.

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Suspicious Activities

• Use telemarketing and door-to-door selling as
  marketing tools.
• Use another person's insurance card to get
  medical care, supplies, or equipment.
• Offer non-medical transportation or housekeeping
  as Medicare-approved services.
• Put the wrong diagnosis on the claim so the
  insurance company will pay.
• Bill home health services for patients who are
  not confined to their home or for Medicare
  patients who still drive a car.
• A friend or stranger asks you to contact your
  doctor and ask for a service or supplies that you
  do not need.
• Offer you payment or gifts to go to clinics or
  offices.

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Write Offs

• Professional Courtesy is discouraged by the AMA.
  (Board of Trustees Report 18-A-98)
• The provider has exhausted all efforts to
  collect, including debt collection agency
• The amount to collect is less than what it costs
  to collect
• The patient has a proven financial hardship.

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Preventing Fraud as a patient

• Never give your health insurance policy number to
  anyone, except your doctor or other health care
  provider.
• Dont allow anyone, except your medical
  providers, to review your medical records or
  recommended services.
• Dont contact your doctor to request a service
  that you do not need.
• Dont ask your doctor to make false entries on
  prescriptions, bills, or records in order to get
  your insurance company to pay.
• Dont accept medical supplies from a door-to-door
  salesman.
• Do be careful in accepting Medical services that
  are represented as being free and then the
  provider asks you for your insurance card.
• Do be cautious when you are offered free testing
  or screening in exchange for your health
  insurance card number.

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Preventing Fraud As A Provider

• Verify insurance information BEFORE the patient
  is seen. Use Insurance Affidavit form.
• Ensure that your coders and medical billers have
  the proper training
• Discourage Percentage Billing
• Verify all claims as 100 true, accurate and
  complete before sending them for payment.
• Perform unannounced audits of claims and payment
  postings.
• Review all EOBs for accuracy.
• Validate all bank deposits against payment
  postings.
• Take Patient Complaints Seriously

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Preventing Fraud as a Provider

• Maintain appropriate documentation
• Record start and stop time
• Understand which services are covered vs.
• non-covered (i.e. non-billable)
• No duplicate claims
• Maintain legible records
• Comply with State licensure regulations
• Cooperate with any audits or reviews
• Avoid up-coding or down-coding

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Is This Fraud or Abuse?
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Questions?
steve_verno_at_yahoo.com
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Thank You
steve_verno_at_yahoo.com
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About the Author

• Steve Verno is a certified medical billing
  specialist, an on line certified medical billing
  specialist instructor, a certified multispecialty
  coding specialist, a certified emergency medicine
  coding specialist, and a certified practice
  manager-medical coding specialist. His
  specialties include Emergency Medicine, Family
  Practice, Urgent Care, Pediatrics, Internal
  medicine, ERISA, Compliance, ICD-10-CM, Appeals,
  AR Recovery, Provider Insurance Contracts. He is
  a retired American Red Cross Health and Safety
  Instructor Trainer and a Professor of Coding and
  Billing at Florida Metropolitan University on
  medical leave. Steve attended the American Red
  Cross college. He has more than 40 articles on
  coding and billing published in BC Advantage
  Magazine and Codetrends Newsletters. He is a
  contributing editor for the Insurance Handbook
  for the Medical Office by Marilyn Fordney. Steve
  has created ICD-10-CM and Appeal guidebooks
  available through BC Advantage. He is a member
  of the Medical Economics Committee of the Florida
  College of Emergency Physicians and an editorial
  board member of BC Advantage, The Medical
  Association of Billers and The Coding Institute.