Fraud and Abuse Chapter 14

Transcription

1 Chapter 14 Cntents Intrductin 1. Zne Prgram Integrity Cntractrs (ZPICs) 2. Defining Fraud and Abuse 3. Prcedures fr Handling Fraud and Abuse Situatins 4. Prtect Yurself frm Fraud 5. ZPIC Cntact Infrmatin Intrductin Medicare Fraud and Abuse The Medicare prgram prvides reimbursement fr health care services fr millins f beneficiaries and prvides payment t tens f thusands f prviders and suppliers f services. Numerus public and private rganizatins are invlved in the prgram s administratin. Within a prgram f such cmplexity and magnitude, the pprtunities fr fraud, abuse, and waste are cnsiderable. The quality cntrl effrt t eliminate fraud, abuse, and waste is necessarily a cperative effrt invlving the beneficiaries, cntractrs, Quality Imprvement Organizatins, state Medicaid agencies, and federal agencies such as the Centers fr Medicare & Medicaid Services (CMS), the Office f the Inspectr General (OIG) and the Department f Health and Human Services (DHHS). Mst suppliers and supplier rganizatins are als interested in fraud and abuse cntrl t prtect their industry s image with the public and Cngress. 1. Zne Prgram Integrity Cntractrs (ZPICs) CMS Manual System, Pub , Medicare Prgram Integrity Manual, Chapter 4, 4.2 Zne Prgram Integrity Cntractrs (ZPICs) are respnsible fr ensuring the integrity f all Medicare-related claims under Parts A and B (hspital, skilled nursing, hme health, prvider and durable medical equipment claims), Part C (Medicare Advantage health plans), Part D (prescriptin drug plans) and crdinatin f Medicare-Medicaid data matches (Medi-Medi). ZPICs are divided int seven znes acrss the cuntry, three f which cver the states that encmpass DME MAC Jurisdictin C. The functins and activities f the ZPICs allw Medicare Administrative Cntractrs (MACs) t place greater fcus n claims prcessing and custmer service, while the ZPICs cncentrate n benefit integrity issues. ZPICs are respnsible fr identifying cases f suspected fraud and making referrals f all such cases t the OIG, regardless f dllar threshlds r subject matter. ZPICs use a variety f tls including data analysis, fraud cmplaints, and referrals. They als develp innvative tls and techniques t identify ptential Medicare fraud and abuse. These appraches are used in building and referring cases t law enfrcement invlving thse wh are suspected f perpetrating Medicare fraud. The three ZPICs which service DME MAC Jurisdictin C are as fllws: AdvanceMed Crpratin Beginning January 1, 2010, AdvanceMed is the ZPIC respnsible fr the fllwing states: Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 1

2 Alabama, Arkansas, Gergia, Luisiana, Mississippi, Nrth Carlina, Suth Carlina, Tennessee, Virginia, and West Virginia Health Integrity, LLC Beginning February 2, 2009, Health Integrity, LLC is the ZPIC respnsible fr the fllwing states: Texas, New Mexic, Clrad, and Oklahma SafeGuard Services, LLC Beginning February 2, 2009, SafeGuard Services, LLC is the ZPIC respnsible fr the fllwing states/territries: Flrida, Puert Ric, and the U.S. Virgin Islands ZPIC Respnsibilities The ZPICs have the respnsibility t: Investigate allegatins f fraud made by beneficiaries, prviders, suppliers, CMS, OIG, and ther surces, including practive data analysis results and pre and pst pay medical review fr benefit integrity. Explre all available surces f fraud leads in its zne. Refer investigatins t the Office f Inspectr General/Office f Investigatins (OIG/OI) fr cnsideratin f civil and criminal prsecutin and/r applicatin f administrative sanctins. Supprt law enfrcement in requests fr infrmatin, including but nt limited t data and data analysis, cst reprt data, and medical review. Recmmend administrative actins t CMS, such as suspending Medicare payment, identifying and recuping verpayments, pursuing civil mnetary penalties, and recmmending prgram exclusins. Prevent fraud by identifying prgram vulnerabilities t CMS. Wrk cperatively with law enfrcement and ther partners, including CMS, affiliated cntractrs (Fiscal Intermediaries, Cntractrs and Medicare Administrative Cntractrs r MACs), Harkin Grantees, prviders, suppliers, and ZPICs t fight fraud and abuse Initiate and maintain netwrking, educatin, and utreach activities t ensure effective interactin and exchange f infrmatin with internal cmpnents as well as utside grups, suppliers, prviders, and beneficiaries. 2. Defining Fraud and Abuse CMS Manual System, Pub , Medicare Prgram Integrity Manual, Chapter 4, Fraud is intentinal deceptin r misrepresentatin that an individual makes, knwing it t be false and that it culd result in sme unauthrized benefit t them. Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 2

3 Abuse describes incidents r practices f prviders, physicians, r suppliers f services and equipment which, althugh nt usually fraudulent, are incnsistent with accepted sund medical, business, r fiscal practices. These practices may, directly r indirectly, result in unnecessary csts t the Medicare prgram, imprper payment, r payment fr services which fail t meet prfessinally recgnized standards f care r which are medically unnecessary. Defining a Cmplaint f Fraud and Abuse A cmplaint is a statement, ral r written, alleging that a prvider, supplier, r beneficiary received a Medicare benefit f mnetary value, directly r indirectly, vertly r cvertly, in cash r in kind, t which they are nt entitled under current Medicare law, regulatins, and/r prgram plicy. Included are allegatins f misrepresentatin and vilatins f Medicare requirements applicable t persns r entities that bill fr Medicare-cvered items and services. Examples f cmplaints include: Allegatins that items r services are nt received; Allegatins that the services received are incnsistent with the services billed (as indicated n the Medicare Summary Ntice); Allegatins that a supplier has billed bth the beneficiary and Medicare fr the same item r service; Allegatins regarding the waiver f cinsurance r deductibles; Allegatins that a supplier has misrepresented itself as having an affiliatin with an agency r department f state, lcal, r federal gvernment, whether expressed r implied; and/r Beneficiary inquiries cncerning payment fr an item r service, which in his r her pinin, may far exceed a reasnable payment fr the service which they received, (i.e., the supplier r physician has upcded t receive a higher payment). The fllwing are nt fraud and abuse cmplaints: Fraud Cmplaints (r inquiries) regarding Medicare cverage plicy; Cmplaints (r inquiries) regarding the status f claims; Requests fr claims appeal r cmplaints regarding the appeals prcess; and/r Cmplaints cncerning suppliers (ther than thse cmplaints meeting the criteria established) which are general in nature and are plicy r prgram riented. The mst frequent type f fraud arises frm a false statement r misrepresentatin which is material t entitlement r payment under the Medicare prgram. The vilatr may be a supplier f durable medical equipment, a beneficiary, r sme ther persn r business entity (e.g., a prescribing physician). Fraud in the Medicare prgram takes such frms as, but is nt limited t: Billing fr services r supplies that were nt prvided; Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 3

4 Supplier claim frms which have been altered t btain a higher payment amunt (i.e., falsifying a beneficiary s address t a DME MAC jurisdictin with higher fee schedule amunts; r using a beneficiary s hme address when in fact the beneficiary is in a nursing hme); Supplier s deliberate applicatin fr duplicate payment (i.e., billing bth Medicare and the beneficiary fr the same service r billing bth Medicare and anther insurer in an attempt t get paid twice); Sliciting, ffering, receiving, r giving a kickback, bribe, r rebate, in exchange fr referring a patient r arranging fr referral f a patient; Physician signing f Certificates f Medical Necessity (CMNs) fr patients nt persnally and prfessinally knwn t the physician; False representatin with respect t the nature f services rendered, amunts charged fr services rendered, identity f the persn receiving the services, dates f services, etc.; Claims fr nn-cvered services billed as cvered services; Claims invlving cllusin between a prvider and a beneficiary r between a supplier and a prvider resulting in unwarranted r higher csts r charges t the Medicare prgram; Use f anther persn s Medicare card in btaining medical services; Repeated vilatins f the participatin agreement r the assignment agreement; Unbundled r fragmented charges (e.g., billing fr parts f an stmy bag); Falsificatin f CMNs (e.g., misrepresenting the diagnsis fr the patient t justify the services r equipment furnished, indicating a patient cannt swallw when in fact he r she can t justify enteral nutritin); Falsificatin f qualifying tests (e.g., exercising a patient befre ximetry r ABG testing). Abuse The type f abuse t which Medicare is mst vulnerable is ver-utilizatin f medical and healthcare services. Abuse takes such frms as, but is nt limited t: Breaches f assignment agreements which result in beneficiaries being billed fr disallwed amunts n the basis that such charges exceeded the reasnable charge criteria (unless Advance Beneficiary Ntice applies); Claims fr services nt medically necessary r nt medically necessary t the extent rendered (e.g., an electric hspital bed is supplied where a manual bed wuld be medically sufficient); Rutine waiver f cinsurance and/r deductibles; Excessive charges fr services r supplies; Imprper billing practices which include: Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 4

5 Supplier failure t file nn-assigned claims, Supplier billing Medicare at a higher and different fee schedule rate than they wuld fr a nn-medicare patient, Submissin f bills t Medicare instead f third-party payers which are primary insurers fr Medicare beneficiaries, and/r Unbundled r fragmented charges; Supplier vilatins f Medicare participatin agreements r supplier standards (see Chapter 2 f this manual fr a list f the supplier standards). Althugh these types f practices may initially be categrized as abusive in nature, under certain circumstances they may develp int fraud. Other Illegal Activities Other illegal activities include (but are nt limited t): A supplier cmpleting the sectins f a Certificate f Medical Necessity (CMN) which must be cmpleted by a physician. A supplier misrepresenting itself as having an affiliatin with any agency r department f state, lcal, r federal gvernment, whether expressed r implied. Bribes, Kickbacks, and Rebates Under federal law, Sectin 1877 (b) and 1909 (b) f the Scial Security Act [42 USC 1395 nn (b) and 42 USC 1396h (b)], it is a felny fr anyne t knwingly and willfully ffer, pay, slicit, r receive any payment in return fr referring an individual t anther persn fr the furnishing, r arranging fr the furnishing, f any item r service that may be paid fr by the Medicare r Medicaid prgram. Individuals cnvicted under these felny prvisins may be fined up t $25,000 r imprisned up t five years, r bth. Anyne wh accepts r slicits any payment fr referring patients t any practitiner, durable medical equipment supplier, hme health agency, labratry, r any ther health prvider r facility which furnishes items r services that may be paid fr by Medicare r Medicaid may be subject t prsecutin. The criminal statute applies regardless f whether the payment fr referral is made directly r indirectly, vertly r cvertly, in cash r in kind. The fllwing are examples f ptential vilatins f federal law if the services are cvered under the Medicare r Medicaid prgrams: Physicians wh are ffered percentages f Medicare payment either acting in the capacity f a cnsultant, attending physician, etc., if they refer patients needing DMEPOS services t specific DMEPOS suppliers. Skilled Nursing Facilities r Nursing Hmes wh are ffered at n charge Durable Medical Equipment (DME), frmula fr nn-medicare-eligible beneficiaries (i.e., Medicaid-eligible beneficiaries), r cmputers and/r billing services, r a rebate n the 20 percent cinsurance as an inducement t refer patients needing Parenteral r Enteral Nutritin (PEN) t a specific PEN supplier. Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 5

6 Hspital scial wrkers r discharge planners wh receive payment frm DME suppliers fr referring hspital patients wh will need hme medical equipment nce they are discharged frm the hspital. In the examples listed abve, the unlawful activity is nt the referral but the slicitatin, receipt, ffering, r giving f payment r free items/services. A referral f a patient that des nt invlve a slicitatin r ffer, r result in the receipt f a gift f any payment r free items wuld nt be cnsidered a vilatin f the statute. Furthermre, these examples are nt all-inclusive f the types f kickback arrangements that are vilatins f the law. 3. Prcedures fr Handling Fraud and Abuse Situatins Yu may cntact the apprpriate ZPIC using the cntact infrmatin fund at the end f this chapter. Yu may als call the OIG at their fraud htline at HHS-TIPS. Please be specific abut the ptential fraud yu suspect. Yu may remain annymus if yu prefer. Dcumentatin Unsubstantiated allegatins frm suppliers will be accepted and recrded in Benefit Integrity Unit files; hwever, investigative actin will nt be initiated until sme verificatin f the allegatin is received. This nt nly will preserve limited investigative resurces, but will prtect inncent suppliers frm false r vindictive allegatins by unfriendly cmpetitrs. Penalties Prviders and suppliers may be subject t up t a $25,000 fine and a five-year imprisnment term, r bth per vilatin, under the applicable federal law and suspended frm the Medicare prgram. Civil penalties include $2,000 fines plus duble damages per vilatin and exclusin. Administrative remedies fr abuse include revcatin f assignment privileges, withhlding f payments, recvery f verpayments, educatinal cntacts and/r warnings, as well as exclusin frm the Medicare prgram. Keep in mind that the suspects in Medicare fraud and abuse are seldm beneficiaries. Mst ften the suspects are suppliers r physicians. Many times the beneficiaries are witnesses in suspected fraud and abuse cases. 4. Prtect Yurself frm Fraud What yu can d as a Medicare supplier t prtect yurself frm fraud: Be infrmed: It is imprtant t understand Medicare eligibility criteria, cverage guidelines, billing, and cst reprt requirements. Seek clarificatin frm yur DME MAC as necessary and attend training pprtunities by CMS and Medicare cntractrs. Be an educatr: Keep beneficiaries prperly infrmed and educated abut the care r supplies yu are prviding, and ensure the physician is actively invlved in the planning and delivery f yur service t the beneficiary. Many recent OIG htline reprts by beneficiaries relate t billing and service issues. Yu can prevent inapprpriate referrals frm beneficiaries if yu have Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 6

7 infrmed beneficiaries and family members f Medicare rules and plicy. Always prvide cmplete and accurate infrmatin t beneficiaries accrding t yur participatin agreement. Be in cmpliance: If yur agency des nt have a cmpliance prgram in place, develpment f ne shuld be cnsidered. The OIG has develped a number f mdel cmpliance prgrams fr prviders and suppliers t use as guidance in develping individual agency prgrams. These prgrams, alng with ther pertinent infrmatin can be fund n the OIG website at r by cntacting the OIG directly. Be a respnsible emplyer: Every supplier shuld be aware f and use the OIG s Sanctin List. This list identifies Medicare prviders wh have been restricted frm participatin in gvernment prgrams. Fr yur prtectin, the list shuld be checked prir t hiring new emplyees t ensure the gvernment has nt sanctined the prspective emplyee. The OIG Sanctin List can be accessed via the OIG website at address Be a Medicare Anti-Fraud Team member: Yu may cntact the apprpriate ZPIC using the cntact infrmatin fund at the end f this chapter. Yu may als call the OIG at their fraud htline at HHS.TIPS. Please be specific abut the ptential fraud yu suspect. Yu may remain annymus. 5. ZPIC Cntact Infrmatin Yu may cntact the apprpriate ZPIC using the infrmatin belw: AdvanceMed Crpratin Zne Prgram Integrity Cntractr Alabama, Arkansas, Gergia, Luisiana, Mississippi, Nrth Carlina, Suth Carlina, Tennessee, Virginia, and West Virginia Website: Health Integrity, LLC Zne Prgram Integrity Cntractr Texas, New Mexic, Clrad, and Oklahma Website: SafeGuard Services, LLC Zne Prgram Integrity Cntractr Flrida, Puert Ric, and the U.S. Virgin Islands Website: Fall 2015 DME MAC Jurisdictin C Supplier Manual Page 7