Understanding Definitional Semantics
Staff Reporters
Fraud Defined
Fraud may be defined as any illegal healthcare activity where someone obtains something of value without paying for, or earning it. In healthcare, this usually occurs when someone bills for services not provided by the physician.
Abuse Defined
According to the www.HealthDictionarySeries.com, healthcare abuse is the activity where someone overuses or misuses services.
And, according to the Center for Medicare and Medicaid Services [CMS]:
“although some of the practices may be initially considered to be abusive, rather than fraudulent activities, they may evolve into fraud.”
Example:
In the case of healthcare abuse, this may occur when a physician sees the patient for treatment more times than deemed medically appropriate. If there are reported issues or actions from other sources, such as the NPDB or a medical board, a health insurance program can take that opportunity to review healthcare providers’ activities. Most participation agreements allow for this type of scrutiny.
Assessment
And so, now that a workable definition of healthcare fraud and abuse has been proposed, and we have some definitional clarity, any preliminary billing or invoice review program will usually request a sampling of specific medical records. This may progress to an on-site review of any and all medical records of patients that participate in a CMS program. These activities can be generated by the plan’s quality assurance, or quality improvement program, and often are tied to the credentialing process for a provider’s participation.
Conclusion
Please subscribe and contribute your own comments – and definitions – on this topic for the benefit of all our Executive-Post readers.
Citation: Medicare Carrier Manual [14-3-14001] 14001; Part B Medicare Fraud.
Related Information Sources:
Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759
Physician Financial Planning: http://www.jbpub.com/catalog/0763745790
Medical Risk Management: http://www.jbpub.com/catalog/9780763733421
Healthcare Organizations: www.HealthcareFinancials.com
Health Administration Terms: www.HealthDictionarySeries.com
Physician Advisors: www.CertifiedMedicalPlanner.com
Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com or Bio: www.stpub.com/pubs/authors/MARCINKO.htm
Subscribe Now: Did you like this Executive-Post, or find it helpful, interesting and informative? Want to get the latest E-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.
Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos
Filed under: "Doctors Only", Ethics, Healh Law & Policy, Practice Management, Quality Initiatives Tagged: | healthcare abuse, healthcare fraud
Modern eHR Fraud and Abuse
A known problem with electronic, or at least digital, medical records is the use of template-based documentation. And, macros and templates do save time.
However, problems arise when doctors, inadvertently or not, document history or physical exam findings that do not exist. This problem is not new as digital word processing has been used for two decades now. But, the issue occurs more often than you think. Of course, with the traditional medico-legal mindset of “if not documented, it didn’t happen,” does the opposite extreme hold water?
On the other hand, as one anonymous blogger opined, “It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.”
Moreover, it looks just plain un-caring when chart-after-chart, or procedure-after-procedure, reads the same to a discerning quality review person or insurance claims adjuster. It looks even more sinister and evil to a malpractice jury.
And so, should doctors, who know of others who fraudulently document, blow the whistle or issue a more subtle warning to the offending physician? Or, is this just a function of time compressed physicians? What do you do?
Ann Miller; RN, MHA
[Managing Editor]
On False Medical Claims
Billing for medical services at a higher reimbursement level than was justified by the services actually provided constitutes a false claim.
In U.S. v. Lorenzo, a dentist billed for a separate oral examination for cancer that was actually only a part of his regular dental check-up examination. So-called “upcoding” is a basis for a False Claims Act charge, and it can take a number of forms.
For example, if a patient comes into the office for a diagnostic test or a session of some therapy that is not personally delivered by a practitioner, and the practitioner tacks on an office visit to the bill, the claim is obviously false.
A more troublesome area of potential liability, however, arises when the code and the actual intensity of care match up but the documentation does not. The practitioner may have done all the care needed to justify the billing code, but if the documentation is lacking, the claim may be false.
Hope Rachel Hetico RN, MHA
[Managing Editor]
Fraud, Abuse and What Exactly is Unnecessary Medical Care?
It’s become one of those trendy phrases, “unnecessary care.” When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out — “unnecessary care” — like it tastes bad. It’s almost always accompanied by “fraud and abuse,” or a not so subtle accusation that some doctor is profiting off this unnecessary care at the expense of some poor patient.
But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really does know best?
http://www.kevinmd.com/blog/2011/10/unnecessary-care.html
Dr. MJ Leonard