chapyer 7 fraud and abuse Flashcards
What is Fraud
Intentional deception, misrepresentation
Individual knows that the false information reported could result in a benefit to that person.
Billing for services that were not provided
“Up-coding”
False diagnosis
Altering claims
What is Abuse
An incident or practice that is not consistent with sound medical, business, or fiscal practice.
Providing unnecessary care
Providing sub-optimal care
It cannot be proven that abusive acts were committed knowingly, willingly, and intentionally
How is it controlled?
Fraud and Abuse Control Program
Investigates and audits delivery of care and payment
Facilitate enforcement of statutes
Provide education through fraud alerts
Share information with the public and private payers
Fraud Alerts
Notifications of practices that are being investigated so physicians can look at their own practices and make corrections.
OIG also issues Special Advisory Bulletins
Runs programs called Operation Restore Trust, Medicare Integrity Program
OIG – Office of Inspector General
How is Fraud and Abuse Reported?
Self-disclosure
Whistleblowers – many are discovered and reported this way.
OIG has a work plan that identifies areas of suspected fraud. Office should go to the web site to get the most recent “hit list” of problems
HIPPA Privacy Regulations
Law to protect the privacy of personal health information maintained by health care providers.
Law provided for “portability” of health care information electronically.
Computer related requirements of HIPPA
Software handles unique identifiers and new formats
Coding and security standards
Policy/procedure for electronic storage of information
Filing systems for claims
Compliance policy
Worst offense is to obtain
information with intent to sell it, transfer it to others or use it for malicious activities.
$250,000 plus 10 years prison time
HIPPA Risk AssessmentCommon Risk Areas
Open reception area
Reception window left open
Sign-up sheet
Computer screen can be seen
Receptionist discusses insurance and demographics at the window.
Message book left open – patients can see it while at the window
Patients can see chart names as they are walking to their exam room.
Patient overhears conversation in the exam room next to his/hers.
Employee takes a call while in the exam room with the patient.
Another patient’s test results are left on the counter of the patient’s exam room.
Physician’s schedule is placed where anyone can see it – like on the counter
Charts piled at the registration desk or the exit counter.
Stark Law
Physician cannot have a financial relationship with an entity that provides health care services.
Example:
To decide, ask:
- Does office make referrals for Medicare/caid patients?
- Is there a financial relationship between the practice and the referral entity
Compliance Plans
Offices are not required to have compliance plans but…
Having one and implementing it can be very helpful in reducing risk of civil or criminal action.
Plan should do this:
Review billing procedures
Correct weaknesses and errors
Establish controls
Compliance plan – 7 components
Audit and monitoring
Audit and monitoring
Should be performed periodically
5 records for each federal payer
Or 5-10 records for each physician in the practice
Compliance plan – 7 components
Establish practice standards and procedures
Establish practice standards and procedures Coding and billing Reasonable and necessary Documented Kickbacks and self-referrals Record retention
Compliance plan – 7 components
Establish practice standards and procedures
Establish practice standards and procedures
Compliance training
Coding and billing training
Continuing education on compliance issues
Compliance plan – 7 components others
Respond to detected offenses and develop corrective action
Develop (and foster) open lines of communication
Enforce disciplinary standards by adhering to well-publicized guidelines.
Designated Compliance Officer
