Transcript Document

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
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(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
scheme…to 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
by…any 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 person’s 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 don’t
follow good medical practices, resulting in
improper payment, or services that aren’t
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)
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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
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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.
• Don’t allow anyone, except your medical providers, to review your medical
records or recommended services.
• Don’t contact your doctor to request a service that you do not need.
• Don’t ask your doctor to make false entries on prescriptions, bills, or
records in order to get your insurance company to pay.
• Don’t 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?
[email protected]
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Thank You
[email protected]
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About the Author
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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.
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