LMHS COMPLIANCE ORIENTATION Physicians and Midlevel Providers. Avoiding Medicare and Medicaid Fraud & Abuse

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1 LMHS COMPLIANCE ORIENTATION Physicians and Midlevel Providers Avoiding Medicare and Medicaid Fraud & Abuse Revised 06/03/2014

2 LMHS COMPLIANCE PROGRAM 6/30/2014 2

3 Chief Compliance Officer Catherine A. Kahle, Esq. Vice President Legal Services and Corporate Responsibility 6/30/2014 3

4 Corporate Compliance Defined A program that promotes a corporate attitude of doing the right thing. Complying with: State and Federal laws LMHS policies & procedures LMHS Standards of Conduct 6/30/2014 4

5 Compliance Hotline LMHS (5647) It s toll free Available 24/7 Anonymous 6/30/2014 5

6 MEDICARE / MEDICAID FRAUD & ABUSE 6/30/2014 6

7 Source The following portion of this presentation is a shortened version of the Office of Inspector General s (OIG s) educational materials (see reference list) which were developed to assist health care organizations in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste and abuse. 6/30/2014 7

8 OIG s Compliance Education for Physicians OIG Mission: To protect the integrity of Federal health care programs. To promote health & welfare of beneficiaries. Provides a comprehensive overview of fraud & abuse laws. Office of Inspector General U.S. Department of Health & Human Services 6/30/2014 8

9 Health Care Fraud: A Serious Problem Almost a trillion dollars per year spent on Medicare and Medicaid Programs. Fraudulent billings range from 3% to 10%. Fraud, waste & abuse = $30 billion to $100 billion per yr. Drains taxpayer money Puts beneficiary health & welfare at risk Exposure to unnecessary services Takes money away from needed care 6/30/2014 9

10 Fraud, Waste & Abuse Defined Fraud: Obtaining something of value through intentional misrepresentation or concealment of material facts. Waste: Incurring unnecessary costs due to deficient management, practices, systems, or controls. Abuse: Any practice that is not consistent with the goals of providing patients with services that are: 1. Medically necessary, 2. In line with recognized standards, or 3. Fairly priced. 6/30/

11 Fraud and Abuse Laws We will focus on five of the most relevant Federal fraud and abuse laws: False Claims Act Anti-Kickback Statute Physician Self-Referral Statute Exclusion Authorities Civil Monetary Penalties Law 6/30/

12 FALSE CLAIMS ACT 6/30/

13 False Claims Act It is illegal to submit false or fraudulent claims. Claims may be false if the service was / is: Not actually rendered Provided but already covered under another claim Miscoded Not supported by medical record documentation 6/30/

14 False Claims Act Copy-Pasting (Cloning) Allows users to select info from one source and replicate it in another location Copy-paste info that is not updated and verified creates inaccurate info in the medical record. Inappropriate charges may be billed due to the inaccurate info. Inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims. Source: Office of Inspector General (2013). Not all recommended fraud safeguards have been implemented in hospital EHR technology 6/30/

15 False Claims Act Over-documentation False or irrelevant documentation inserted to create the appearance of support for billing higher level services Some EHR technologies auto-populate fields when using built-in templates Other systems generate extensive documentation on the basis of a single click of a check-box If not appropriately edited, the info may be inaccurate and could lead to false claims violations Source: Office of Inspector General (2013). Not all recommended fraud safeguards have been implemented in hospital EHR technology 6/30/

16 False Claims Act Violations Fines up to 3x program s loss Plus up to $11,000 per claim Fines add up quickly because each claim can be a separate ground for liability You do not have to intend to defraud! Can be punished for deliberate ignorance and reckless disregard of the truth 6/30/

17 False Claims Act Incentives to Report Fraud False Claims Act provides strong financial incentive to report fraud. Whistleblowers can receive up to 30% of recovery. Whistleblowers can be: Ex-business partners Hospital / office staff Competitors Patients 6/30/

18 ANTI-KICKBACK STATUTE 6/30/

19 Anti-Kickback Statute Asking for, or receiving any remuneration in exchange for referrals of Federal health care program business is a crime under the Anti-Kickback Statute. Applies to: Both payers and recipients of kickbacks. Just asking or offering can violate the law. 6/30/

20 Anti-Kickback Statute Examples of prohibited kickbacks: Cash for referrals Free or below fair market value rent for medical offices Free clerical staff Excessive compensation for medical directorships Selling your product loyalty to drug or device companies or other vendors 6/30/

21 Anti-Kickback Statute Kickbacks can lead to:» Overutilization of items/services» Increased program costs» Corruption of medical decision making» Patient steering» Unfair competition» Medically unnecessary care 6/30/

22 Anti-Kickback Statute Penalties for Kickbacks Prison Fines Time Program Exclusion 6/30/

23 Anti-Kickback Statute Red Light: Waiving copayments routinely You cannot waive copayments and still bill Medicare & Medicaid (this is like a kickback). Amber Light: Waiving copayments on a case by case basis for financially needy You can waive copayments when patient unable to pay or when reasonable collection efforts fail. Green Light: Providing free / discounted services to uninsured patients You may treat uninsured patients for free or offer them discounts. 6/30/

24 PHYSICIAN SELF-REFERRAL STATUTE (STARK LAW) 6/30/

25 Physician Self-Referral Law (Stark) Prohibits referrals of Medicare / Medicaid patients for designated health services to entities you have a financial relationship with (unless an exception applies) Example: You may not refer patients to an imaging center for designated health services if you have a financial investment in that center, unless an exception applies. 6/30/

26 Physician Self-Referral Law (Stark) Financial Relationships Ownership / investment interests Compensation relationships Law applies to your financial relationships and those of your immediate family members Designated Health Services *Refer to your booklet for a complete list Clinical lab services Physical therapy services Home health services 6/30/

27 Physician Self-Referral Law (Stark) Violators are subject to: Payment denial Repayment (all amounts received from Medicare / Medicaid that are connected with the improper relationship) Monetary penalties Exclusion from Federal health care programs 6/30/

28 EXCLUSION FROM MEDICARE AND MEDICAID 6/30/

29 Exclusion from Medicare / Medicaid OIG may exclude providers from participation in Federal health care programs Two categories: Mandatory Exclusion Imposed on the basis of certain criminal convictions Permissive Exclusion Based on sanctions by other agencies (i.e. state medical board suspending/revoking a medical license), or Other misconduct (i.e. defaulting on health education loans; providing unnecessary or substandard care). 6/30/

30 Exclusion from Medicare / Medicaid May not bill for treating Medicare & Medicaid patients. Services may not be billed indirectly (i.e. through an employer or a group practice). Some refer to exclusion as a financial death sentence. Currently, more than 5,200 physicians are excluded from participation in Federal health care programs. 6/30/

31 CIVIL MONETARY PENALTIES LAW 6/30/

32 Civil Monetary Penalties Law OIG may seek civil monetary penalties for a wide variety of abusive conduct. Examples: Medically unnecessary services Overcharging or double billing Medicare beneficiaries Violating the Anti-Kickback Statute (refer to booklet for further examples) 6/30/

33 Helpful Tips Remember: Ensure accurate coding and billing. Commit to accurate medical record documentation. Write only lawful prescriptions. Avoid suspicious relationships with fellow providers (fellow physicians, hospitals, nursing homes) and vendors. 6/30/

34 Reference List Department of Health and Human Services, Centers for Medicare & Medicaid Services (2012, November). Medicare Fraud & Abuse: Prevention, Detection, and Reporting. ICN Retrieved March 6, 2013, from MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf. Office of Inspector General (n.d.). A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse, which is a booklet for physicians self-study. The Roadmap is available on OIG s website at Office of Inspector General (n.d.). A companion PowerPoint presentation that the OIG encourages organizations to use to teach the material contained in the Roadmap. The PowerPoint presentation is available on OIG s website at 6/30/

35 Reference List Office of Inspector General (n.d.). The speaker note set, which will assist educators in giving the PowerPoint presentation. The speaker note set is available on the OIG s website at Office of Inspector General (n.d.). For physicians who may be unable to attend a live, didactic presentation of the material contained in the Roadmap, the OIG has also provided a narration of the speaker notes to accompany the PowerPoint slides. The narration is available on OIG s website at 6/30/

36 Questions 6/30/

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