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Understanding the Healthcare Fraud and Abuse Control Program

17 Responses

1. Greg, on January 11, 2010 at 8:08 PM said:

   Why?
   Using Dead Doctors to Exploit Medicare
   http://fieldnotes.msnbc.msn.com/archive/2010/01/11/2170075.aspx
   That’s why?
   Gregory

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2. Ann, on March 11, 2010 at 11:30 AM said:

   Obama to Use High-Tech Bounty Hunters to Fight Healthcare Fraud

   President Barack Obama just said that he’ll bring in high-tech bounty hunters to help root out health care fraud, grabbing a populist idea with bipartisan backing in his final push to overhaul the system.

   The bounty hunters in this case would be private auditors armed with sophisticated computer programs to scan Medicare and Medicaid billing data for patterns of bogus claims. The auditors would get to keep part of any funds they recover for the government. The White House said a pilot program run by Medicare in California, New York and Texas recouped $900 million for taxpayers from 2005-2008.

   Obama is placing a heavy emphasis on battling waste and fraud in his final healthcare push. The newly repackaged bill, contained more than dozen anti-fraud ideas. A common theme linking them is the increased use of technology to spot suspicious billing patterns and keep track of service providers with a track record of problems.

   Source: Ricardo Alonso-Zaldivar, Associated Press [3/10/10]

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3. Kellie, on May 12, 2010 at 12:16 AM said:

   Medicare Fraud Risk Created by Billing Loophole

   Did you know that Medicare paid a total of $87 million over 16 months for medical equipment and supply claims in which suppliers listed their own national provider identifiers in place of the NPIs of referring physicians, according to a report from the Dept. of Health and Human Services Office of Inspector General?

   Although these payments were allowed under a temporary provision, they represent a potential risk, because Medicare claims-processing systems did not verify if the equipment actually was ordered by eligible physicians, OIG reported. The oversight agency recommended that the Centers for Medicare & Medicaid Services [CMS] end the practice “at the earliest date possible while maintaining beneficiary access to services.”

   In May 2008, CMS began requiring suppliers to include NPIs for both the supplier and the referring physician on every Medicare claim. But, the agency has been allowing suppliers to use their own IDs in the claims field designated for the referring physician if the supplier is unable to obtain the information from the doctor. CMS plans to end the temporary provision on Jan. 3, 2011, when it will make several changes to its claims processing system. OIG noted, however, that this implementation date already has been postponed twice.

   Source: Chris Silva, AMNews [5/10/10]

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4. Tom, on May 15, 2010 at 10:48 AM said:

   Anti-Fraud Efforts Recover $2.5 Billion

   The government’s efforts to rein in Medicare fraud and abuse recovered $2.5 billion for the program in fiscal 2009, up 29% from $1.9 billion the previous year, according to a new annual report.

   HHS Secretary Kathleen Sebelius and Attorney General Eric Holder touted that number and others as evidence that the Obama administration’s invigorated attention to the problem has paid dividends already, and they highlighted new funding and tools their departments will wield in the fight.

   The $2.5 billion collected in fiscal 2009 is attributed to judgments and settlements in previous years as well as 2009, according to the report of the Health Care Fraud and Abuse Control Program. Another $441 million was returned to the treasury as the federal share of Medicaid recoveries.

   In the criminal realm of healthcare fraud in fiscal 2009, the Justice Department opened 1,014 new investigations compared with 953 in fiscal 2008. Prosecutors charged 803 defendants and won 583 convictions. Those numbers don’t differ significantly from the previous year.

   Source: Gregg Blesch, Modern Healthcare [5/14/10]

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5. Ann Miller RN MHA, on October 19, 2010 at 12:37 PM said:

   73 Indicted in Largest-Ever Medicare Fraud Scheme

   Seventy-three defendants, including a number of alleged members and associates of an Armenian-American organized crime enterprise, were charged in indictments unsealed today in five judicial districts with various health care fraud-related crimes involving more than $163 million in fraudulent billing, announced Acting Deputy Attorney General Gary G. Grindler, FBI Assistant Director of the Criminal Investigative Division Kevin Perkins and Health and Human Services Inspector General Daniel R. Levinson.

   The defendants are charged with engaging in numerous fraud activities, including highly-organized, multi-million dollar schemes to defraud Medicare and insurance companies by submitting fraudulent bills for medically unnecessary treatments or treatments that were never performed.

   According to the indictments, the defendants allegedly stole the identities of doctors and thousands of Medicare beneficiaries and operated at least 118 different phony clinics in 25 states for the purposes of submitting Medicare reimbursements.

   Source: U.S. Department of Justice [10/13/10]

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6. Jim, on October 24, 2010 at 12:13 AM said:

   KY Podiatrist Indicted on 23 Counts of Medicaid Fraud

   A Kentucky podiatrist has been indicted on 23 counts of Medicaid fraud. Attorney General Jack Conway announced today that a Franklin County grand jury indicted Dr. Richard E. Skrip. Skrip is a podiatrist in London. The indictment follows a criminal investigation conducted by the Attorney General’s Medicaid Fraud and Abuse Control Unit into Skrip’s billing practices.

   Skrip, who has offices in several locations in south central and south eastern Kentucky, is charged with defrauding the Kentucky Medical Assistant Program by submitting claims for payment of services totaling approximately $25,000. The indictment alleges Skrip submitted claims for services that he did not perform related to 26 patients between May 2001 and May 2008.

   Source: WKYT [10/22/10]

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7. Jane, on November 13, 2010 at 9:03 PM said:

   Scrutiny Sought for Repeat Offenders on Medicare Claims

   The OIG has targeted the integrity of Medicare payments as one of the top management challenges facing the Centers for Medicare & Medicaid Services.

   For example, from fiscal 2005 to 2008, the agency said it located 740 repeat offenders, including physicians and suppliers of medical equipment that had at least one error in each audit year and referred to them as “error-prone providers. And, CMS could significantly reduce the incidence of improper payments by focusing on these physicians and suppliers.

   Specifically, it recommended that CMS:

   • Use available error rate data to identify error-prone physicians and medical equipment suppliers.
   • Require them to identify the root causes of claims errors and develop and implement corrective action plans.
   • Monitor corrective action plans.
   • Share error rate data with contractors, such as recovery audit contractors and quality improvement organizations, to assist in identifying improper payments.

   Source: Chris Silva, AM News [11/8/10]

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8. Keith, on December 17, 2010 at 11:12 AM said:

   CMS Plans to Use New Anti-Fraud Tools

   The CMS will acquire new tools to prevent wasteful and fraudulent payments in Medicare, Medicaid, and the Children’s Health Insurance Program, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced at regional healthcare fraud-prevention summit in Boston. In conjunction with the summit, the CMS will issue a solicitation for what it called “state-of-the art, fraud-fighting, analytic tools” to help in this effort.

   The tools will integrate many of the agency’s pilot programs into the National Fraud Prevention Program and also complement the work of the joint HHS and Justice Department’s Health Care Fraud Prevention and Enforcement Action Team, or HEAT. The CMS is then expected to use the results to take anti-fraud actions before a claim is paid. According to HHS, the Patient Protection and Affordable Care Act provides an additional $350 million over the next 10 years to the Health Care Fraud and Abuse Control Account.

   Source: Jessica Zigmond, Modern Healthcare [12/16/10]

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9. Ann Miller RN MHA, on October 5, 2011 at 10:25 PM said:

   Feds Crack Down on Fraud, but Should Share Info With Carriers

   A joint effort between HHS and the Department of Justice [DOJ] launched in 2009 is taking a bite out of fraud and abuse in Medicare and Medicaid.

   But, some health plan investigators say federal and state investigators could do a better job of sharing information that could help identify fraud on the commercial side. And, commercial carriers could become more attractive targets as the feds crack down on fraud in Medicare and Medicaid.

   For example, Lee Arian, a former federal prosecutor who heads WellPoint, Inc.’s fraud and abuse unit, said people who commit fraud are just as likely to target commercial carriers as Medicare and Medicaid. He adds that state and federal agencies could do a better job of sharing information with commercial carriers.

   Government agencies “are paying more attention to the commercial side, but there are reasonable concerns about how much information they can share [with commercial carriers]. They don’t want to jeopardize an investigation,”

   And, while he says government agencies are getting better about sharing information with insurers, “I don’t think we’ll ever have a two-way street where we share information freely.”

   Source: Steven Davis, Health Plan Week [9/26/11]

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10. Debra, on February 4, 2012 at 10:18 PM said:

    CMS Sets New Start Date for Anti-Fraud Program

    A CMS anti-fraud program, whose January 1st launch was scrubbed because of provider concerns, will start in June instead, according to the agency.

    The pilot project will allow recovery audit contractors to review claims before they are paid, focusing on the types of claims historically associated with high rates of improper payments in seven states (California, Florida, Illinois, Louisiana, Michigan, New York and Texas), and claims with high volumes for short inpatient hospital stays in four states (Missouri, North Carolina, Ohio and Pennsylvania).

    Source: Rich Daly, Modern Healthcare [2/3/12]

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11. Ann Miller RN MHA, on February 15, 2012 at 10:58 AM said:

    New Overpayment Rules Proposed

    The same day that federal officials unveiled record-breaking statistics on healthcare fraud enforcement, regulators announced the publication of new proposed rules designed to force doctors, hospitals, and suppliers to voluntarily return overpayments within 60 days of discovering them.

    In a recent news conference, HHS Secretary Kathleen Sebelius noted that the rules were intended to cut down on improper payments without the need for criminal or civil investigations. The proposed rule requires healthcare providers to return any overpayments within 60 days of when the erroneous payments were detected.

    Source: Joe Carlson, Modern Healthcare [2/14/12]

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12. Susan, on May 2, 2012 at 7:12 PM said:

    Feds unveil allegations of $450 million in Medicare fraud schemes
    [BREAKING NEWS]

    More than 100 people including doctors, nurses and other health care professionals have just been charged in a series of Medicare fraud schemes that total more than $450 million.

    Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced the arrests at a news conference in Washington.

    http://usnews.msnbc.msn.com/_news/2012/05/02/11504338-feds-unveil-allegations-of-450-million-in-medicare-fraud-schemes?lite

    Susan

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13. Ann Miller RN MHA, on May 7, 2012 at 10:40 AM said:

    Physicians Fight “Unworkable” Medicare Overpayment Rule

    Organized medicine is pushing back against a Medicare proposal to recoup overpayments quickly from physicians, who would be required to go back through up to 10 years of medical records when determining if they received excess pay. The American Medical Association and state and specialty medical organizations have called on the Centers for Medicare & Medicaid Services to clarify — or in some cases abandon — new requirements that practices must return overpayments within 60 days.

    About 110 groups, led by the AMA, sent an April 16 letter to CMS acting Administrator Marilyn Tavenner calling on the agency to make necessary changes before the proposal is finalized. The AMA also sought clarification of what it meant for a physician to identify an overpayment.

    CMS had stated that the rule created an “incentive to exercise reasonable diligence to determine whether an overpayment exists.” But the rule should not imply that doctors must actively search for overpayments from a decade’s worth of claims without some piece of information that would signal that an excess payment might have been received, the Association said.

    Source: Charles Fiegl, amednews [4/30/12]

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14. Selma, on May 15, 2012 at 8:57 PM said:

    Top 9 fraud and abuse areas big data tools can target

    Big-data tools can be used to review large healthcare claims and billing information to target the following:

    1. Assess payment risk associated with each provider
    2. Over-utilization of services in very short-time windows
    3. Patients simultaneously enrolled in multiple states
    4. Geographic dispersion of patients and providers
    5. Patients traveling large distances for controlled substances
    6. Likelihood of certain types of billing errors
    7. Billing for “unlikely” services
    8. Pre-established code pair violation
    9. Up-coding claims to bill at higher rates

    http://www.govhealthit.com/news/part-3-9-fraud-and-abuse-areas-big-data-can-target?topic=30,31,18

    Can you think of any others?

    Selma

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15. Dr. Howard, on May 30, 2012 at 1:36 AM said:

    HHS Touts Anti-fraud Efforts in Midyear Report

    In a report to Congress, HHS Inspector General Daniel Levinson said officials in his office expect to recover $1.2 billion from audits and investigations reported during the first half of 2012.

    The 114-page report (PDF) says the tally for half a year’s work includes the expected collection of $748 million from investigations and $483 million from audits. The office also filed 346 new criminal cases and 138 civil actions between October 2011 and March 2012 against people or companies accused of healthcare offenses against HHS.

    Source: Joe Carlson, Modern Healthcare [5/29/12]

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16. Ann Miller RN MHA, on May 14, 2013 at 9:48 AM said:

    Docs Press AMA to ‘Educate’ Feds on EHR Use

    The New Jersey delegation to the American Medical Association’s House of Delegates meeting next month wants the AMA to “educate” the CMS that the appropriate use of templates and cutting and pasting within an electronic health-record system is not tantamount to fraud. The request comes in the form of a resolution proposed for the annual meeting of delegates set for June 15-19 in Chicago.

    It was issued in response to a controversy that arose late last year when HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder jointly warned providers about rising levels of evaluation and management codes, suggesting EHRs might be used to fraudulently code patient encounters.

    The New Jersey resolution said “federal enforcement authorities appear to have a presumption that any increased medical costs are the result of fraud and not the result of better documentation of clinical services provided.”

    Source: Joseph Conn, Modern Physician [5/13/13]

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17. Robert James Cimasi MHA AVA ASA CMP™, on December 23, 2013 at 11:11 PM said:

    Emboldened Government Pursuit and Prosecution of Healthcare Fraud and Abuse

    Since 1998, the government agencies responsible for prosecuting healthcare fraud and abuse, the Department of Justice and Office of Inspector General, have demonstrated an increased willingness to pursue claims under the Anti-Kickback Statute, the Stark Law, and the False Claims Act, as well as to prosecute increasingly complicated sets of violations.

    Click to access Emboldening%20the%20Government.pdf

    Part one of this three part series introduces the statutory and regulatory framework of the relevant statutes, the teams responsible for investigating healthcare fraud and abuse, and the relevant theoretical concepts involved in healthcare fraud and abuse lawsuits.

    Robert James Cimasi MHA AVA ASA CMP™
    http://www.HealthCapital.com
    via Ann Miller RN MHA

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