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Patient Bounty Hunters
By Dr. David Edward Marcinko; MBA, CMP™
Publisher-in-Chief
Fraud and Abuse Reporting Incentives
Under the Health Insurance Portability Accountability Act, the Department of Health and Human Service (HHS) has operated an “Incentive Program for Fraud and Abuse Information”, since January 1999.
In this program, HHS pays $100-$1,000 to Medicare recipients who report abuse in the program. To assist patients in spotting fraud, CMS has published examples of potential fraud, which include:
- Medical services not provided
- Duplicate services or procedures
- More expenses services or procedures than provided (upcoding/billing).
- Misused Medicare cards and numbers
- Medical telemarketing scams
- Non-medical necessity.
And, there is no question that real fraud exists.
For example, the Office of Inspector General of the Department of Health and Human Services (HHS) saved American taxpayers a record $21 billion in Fiscal-Year 2003-04, according to former Inspector General Janet Rehnquist.
Savings were achieved through an intensive and continuing crackdown on waste, fraud and abuse in Medicare and over 300 other programs for which the Office of Inspector General. (OIG) had oversight responsibility.
At last report, the agency performed or oversaw 2,372 audits, conducted 70 evaluations of department programs, and opened 1,654 new civil and criminal cases, bringing to more than 2,700 the number of active OIG investigations.
Additionally, the OIG excluded 3,448 individuals and entities from participation in Medicare, Medicaid and other federally sponsored health care programs, and its enforcement efforts resulted in 517 criminal convictions and 236 successful civil actions.
To discourage flagrant allegations, regulations require that reported information must directly contribute to monetary recovery for activities not already under investigation.
Nevertheless, expect a further erosion of patient confidence, as they begin to view healthcare providers in the same light as “bounty hunters”.
Doctors – has a patient “turned-you-in” needlessly – yet?
More on risk management: http://www.jbpub.com/catalog/9780763733421
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[…] Here is an interesting post today with a quick excerpt by Dr. David Edward Marcinko; MBA, CMP™ Publisher-in-Chief. Fraud and Abuse Reporting Incentives. Under the Health Insurance Portability Accountability Act, the Department of Health and Human Service (HHS) has operated an “Incentive Program for … […]
Editor’s Note: And for related risk management information, take a look at:
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For related information:
http://www.jbpub.com/catalog/9780763733421/
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I am getting faxes from an unidentified source “A New HealthCare Reform Package” 89.50/month. I’m sure it’s a scam as there is no name of any Insurance company (or other) or provider at all. The number to call is 877-390-0032. It states in fine print at the bottom “This is in response for your request for information. This is not a solicitation. If you have received this fax in error and wish to be removed from our database, register at http://www.fax-hault.com or call 1-866-211-9589.
I NEVER, NEVER use my fax number as a contact for a request for information……my first clue…..Secondly, I googled the 877 number and there are dozens of others who did n fact call and were” sold” a product but couldn’t get any information about who the company was. Consequently people reported that when they continued to ask questions they were hung up on. They reported that when they called back they were hung up on again.
I’m thinking identity theft….?
I know several “well educated people” that have wondered if this was legit. Everyone needs help in that department. I suspect there will be many who go for it.
Jay Wats
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Waste accounts for $850B of healthcare costs annually
Read more: http://www.fiercehealthcare.com/story/u-s-healthcare-system-wastes-850b-year-report-says/2009-10-26#ixzz0VjhP9DHW
Mike
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Providers Have Won Majority of Appealed RAC Claims Denials
The latest RAC appeals data show the tide turning in favor of providers, who have prevailed in two-thirds of the claims denials they fought to have overturned. The updated data — the first that CMS has released in more than a year — indicate that it’s worth appealing claims denials when hospitals believe they have a strong leg to stand on.
According to CMS’s June 2010 RAC update, 598,238 claims have been subject to RAC overpayment determinations as of March 9. Providers appealed 76,073 of those claims, and were victorious 64.4% of the time, which means 8.2% of the claims were overturned on appeal.
Source: Nina Youngstrom, Report on Medicare Compliance [7/21/10]
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Why upcoding isn’t necessarily fraud
An essay by Juliet K. Mavromatis MD.
http://www.kevinmd.com/blog/2012/10/upcoding-necessarily-fraud.html
Ann Miller RN MHA
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