Fraud, Waste and Abuse Training for Providers

Transcription

1 Fraud, Waste and Abuse Training for Providers

2 What You ll Learn Definitions of fraud, waste and abuse Examples of each Relevant statutes Your responsibilities

3 Fraud, Waste and Abuse Accounts for billions lost Who pays? Patients Working people Honest providers

4 Why FWA Training? CMS mandates it! Initial training by 12/31/09 Attestation due 01/01/10 Annual training Providers must maintain records

5 Why FWA Training? The NYS Insurance Department also mandates fraud training, Second Amendment to Regulation 95 (11 NYCRR 86) Section 86.6 (6) states the following: Provision for in service training programs for investigative, underwriting and claims personnel in identifying and evaluating instances of suspected insurance fraud, including an introductory training session and periodic refresher sessions. The Insurance Department has stated that this periodic training is required every other year.

6 What Is Health Care Fraud? Title 18 U.S. Code, Section 1347 NYS Law Article (Insurance Fraud) of the Penal Law also defines fraud in the same manner. Keys words Intent, knowledge and willingness False or fraudulent pretenses Delivery of payment for health care benefits Unauthorized benefit to the perpetrator or some other person

7 Examples of Health Care Fraud Follow up visit billed as initial Toenail trim billed as surgery Charges for blood tests not done Billing for expensive wheelchair; delivering a standard one Billing for different item or service or one not provided.

8 What Is Health Care Waste? Practices resulting in unnecessary cost Overuse, underuse and misuse of care Non value added services Medical mistakes; medication errors Overuse of emergency departments Unnecessary lab tests and imaging

9 What Is Health Care Abuse? Unnecessary, inappropriate care Care doesn t meet professionally recognized standards Provider conduct inconsistent with acceptable business and/or medical practices resulting in greater reimbursement

10 Examples of Health Care Abuse Billing for medically unnecessary items or services Services exceed what is needed Billing for a non covered service Misusing codes on a claim Waste/abuse may become fraud

11 Who Commits Health Care Fraud? Providers and staff Members/Beneficiaries Health insurance employees Pharmacy personnel Vendors Scammers

12 Examples of Provider Fraud Upcoding Duplicate billing Ghost beneficiaries Misrepresenting services Unbundling services Phantom billing Billing for free services

13 How can health care fraud happen? People trust their doctors Only doctors decide what is medically necessary Elderly patients or those with disabilities especially vulnerable Intimidated by health care system Reluctance to question doctor for fear of negative impact

14 Examples of Member/Beneficiary Fraud Identity swapping Identity theft Doctor shopping Resale, inappropriate use or diversion of prescription drugs Forging or altering bills, receipts or prescriptions

15 Laws and Regulations The False Claims Act The Anti Kickback Statute Physician Self Referral Statute Health Insurance Portability and Accountability Act of 1996 Civil monetary penalties NYS Law, Article 176 of the Penal Law (Insurance Fraud)

16 The different degrees of fraud Insurance fraud in the fifth degree Class A misdemeanor Insurance fraud in the fourth degree Class E felony (in excess of $1,000 fraud) Insurance fraud in the third degree Class D Felony (in excess of $3,000) Insurance fraud in the second degree Class C felony (in excess of $50,000) Insurance fraud in the first degree Class B felony (in excess of $1 million) Aggravated insurance fraud Class D felony (when a person commits a fraudulent insurance act and has been previously convicted within the preceding 5 years of any offense)

17 Federal False Claims Act Legal tool to counteract fraudulently billing government. Allows private citizens to sue on behalf of the government, i.e., whistle blowing. May receive 15 to 25 percent of recovery.

18 False Claims Penalties Three times the amount of damages Civil penalties of $5,500 to $11,000 per false claim One false claim of $100 results in penalty 114 times original claim NYS insurance law, 2 nd amendment to regulation 95 also states that civil fines for false claims are valued at $5,000 plus the value of each claim.

19 How penalties can add up One false claim for $100 what the government was billed. Triple the damages that s 3 times $100 or $300. Add the maximum penalty of $11,000. $100 + $300 + $11,000 dollars = $11,400 Staying out of trouble with the government priceless.

20 Anti Kickback Statute Prohibits knowingly or willingly Inducing or rewarding referrals of business payable under a federal health program Falsely applying for benefits or payments Concealing or failing to disclose knowledge

21 Anti Kickback Statute Penalties Felony conviction Imprisonment up to five years and Up to $25,000 fine Possible exclusion from federal health care programs

22 Physician Self Referral Statute Stark I: no referrals to physician/family owned business or compensated by same Stark II: extends relationship to entities providing designated health services under Medicare Exceptions and safe harbors

23 Stark Penalties Denial of payment Refund of amounts up to $15,000 for each service collected Civil monetary penalties up to $100,000 per occurrence

24 HIPAA Health Insurance Portability and Accountability Act Obtain or disclose individually identifiable health information Specific knowledge of a violation is not required to be penalized

25 HIPAA Violation Penalties HIPAA Civil Penalties $100/violation up to $25,000/year HIPAA Criminal Penalties $50,000/up to 1 year in prison $100,000 fine/up to 5 years for false pretenses $250,000/up to 10 years with intent to sell

26 Civil Monetary Penalties Prohibits claims for services that the individual or entity ʺknows or should knowʺ were not provided as claimed Can t claim ignorance Prohibits providing false or misleading information on coverage to influence when to discharge an inpatient from the hospital

27 Civil Monetary Penalties Up to $10,000 per claim or $15,000 for each individual for false or misleading information Assessment payments up to three times amount claimed The greater of $5,000 or three times the amount of payments for services if physician certifies need for home health knowing all conditions for care not met

28 Beneficiary Inducements Remuneration that the Medicare or Medicaid beneficiary knows or should know is likely to influence his/her selection Remuneration includes Cash Waivers of copayments/deductibles Transfer of items or services for free or other than fair market value Non cash items, gifts or services

29 Beneficiary Inducement Penalties Fines up to $10,000 per violation, plus Three times damages incurred by the government Potential exclusion from participation in government programs Civil monetary penalties may apply

30 OIG/GSA Exclusion/Debarment Protects government from doing business with those who pose a business risk to the government Prevents companies/individuals from participating in government programs

31 OIG Exclusions From Gov t t Programs Payment ban applies to all methods of federal program reimbursement, including Itemized claims Cost reports Fee schedules Prospective payment system

32 OIG Exclusions continued Items/services furnished or ordered by an excluded person Items/services furnished to a hospital inpatient or outpatient based on an excluded person s orders Administrative and management services not directly related to patient care but necessary to provision of care and items.

33 OIG Exclusions continued Services reimbursed through prospective payment or bundled physician group Processing of claims submitted to a Medicare fiscal intermediary Services by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer Items or equipment sold by an excluded manufacturer or supplier and used to treat or care for beneficiaries

34 OIG/GSA Exclusion/Debarment Hiring prohibition Civil monetary penalty $10,000/claim submitted for services/ items furnished during exclusion Knew or should have known person excluded Affirmative duty to check employees exclusion status Web site list: hhs.gov/oig

35 Your Responsibilities Know/follow applicable laws, regulations, policies, procedures Report known/suspected violations Do annual compliance/specialized Medicare compliance training Adhere to your Code of Conduct Do not retaliate

36 Reporting Potential FWA Univera Healthcare Special Investigations Department 205 Park Club Lane Buffalo, NY Hotline: Buffalo Rochester Central NY Utica Web site: Ethics & Compliance Officer Susan Emhof Ethics & Compliance Hotline:

37 Fraud & Abuse Resources Medicare Fraud & Abuse brochure Univerahealthcare.com Medicare.gov NYS insurance laws

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