Fraud and Abuse and How it Affects the Coder

Transcription

1 Fraud and Abuse and How it Affects the Coder Presented by: Laura E Hill, CPC, CPC-I, MCS-P

2 What is Fraud? In the simplest terms, fraud occurs when someone knowingly and with intent to defraud, presents or causes to be presented, any written statement that is materially false and misleading to obtain some benefit or advantage, or to cause some benefit that is due to be denied. 2

3 What is Abuse? Abuse occurs when doctors or suppliers don t follow good medical practices, resulting in unnecessary costs to healthcare. 3

4 Fraud and Abuse The real difference between fraud and abuse is the person s intent. Both activities have the same impact: they detract valuable resources from the insurance plan funds. 4

5 Fraud and Abuse Most providers of services (physicians, suppliers, and other healthcare workers) are honest hard working people. However, some willfully enter into the healthcare system to perpetrate fraud, and some intentionally and consistently defraud insurance companies by padding their bills. 5

6 Ethics For the Medical Coder The Professional Coder has a duty to code medical services and procedures to the best of his/her ability. It is imperative that the coder knows his/her limitations. Ask for help and direction. Rules and guidelines change constantly! Know where to look for correct information. 6

7 The Coders Role Become both an emissary and an educator with their providers and other members of the staff. Encourage the implementation and use of a compliance plan. Teach and implement strategies for correct coding. Report to the compliance officer any fraudulent coding. 7

8 The Coders Role It is more important to get the correct answer than to portray false knowledge. Follow the Coder s Golden Rule IF IT IS NOT DOCUMENTED, IT CAN NOT BE BILLED 8

9 Best Practices for a Coder Maintain the highest standards of personal and professional conduct. Respect the rights of patients, clients, employers, and all other colleagues. Use only legal and ethical means in all professional dealings. 9

10 Starting with the Medical Record The medical record serves many functions Outlines the patient s care and treatment rendered Used in medical research Used for health care statistical measurements Supporting tool for reimbursement Legal document 10

11 The Medical Record as a Legal Document The patients chart is a legal document and as such should never be tampered with, altered or falsified in any manner that would cause the loss of, or suppression of, data. 11

12 The Medical Record and Compliance Issues The medical record supports not only treatment compliance but also patient compliance. From a Fraud or Abuse issue, the medical documentation must support and/or drive the coding of medical services/procedures. 12

13 Lets look again at Fraud and Abuse The most frequent kind of medical fraud arises from a false statement or misrepresentation made or caused to be made that is material to entitlement or payment under a medical plan (the most significant is the largest government plan, Medicare) 13

14 Lets look again at Fraud and Abuse The following are some of the most frequently used schemes to commit fraud: Billing for services not furnished Misrepresenting the diagnosis to justify payment Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment Billing for medical equipment that has been returned or is not in use 14

15 Fraud and Abuse Violators may be: Physicians or other practitioners Hospitals or other institutional provider Clinical laboratories or other suppliers An employee of any provider A billing service A beneficiary YOU 15

16 Lets look again at Fraud and Abuse Under the broad definition of fraud are other violations, including: Offering or acceptance of kickbacks Routine waiver of copayments/coinsurances Fraudulent coding activities including unbundling, undercoding, and upcoding 16

17 Unbundling Unbundling refers to the separate reporting (coding) of services or procedures inherently part of another service or procedure. Unbundling is also called fragmenting service and it is considered fraud! Coders should use the CCI Edits (Correct Coding Initiative) which will help identify many unbundling issues. 17

18 Undercoding Billing for a service that is less than that actually rendered and/or documented is considered undercoding. Many providers see this as a safe practice for coding and billing their services, HOWEVER, this practice, according to the OIG and CMS, is considered a prosecutable form of fraud. Flying under the radar can actually be a red flag that will cause the provider a lot of trouble. 18

19 Upcoding Upcoding or overcoding refers to the practice of coding and billing for a service that is worth more when a lesser service has been provided and/or DOCUMENTED. 19

20 Abuse Abuse is a term associated with providers whose medical, business, or fiscal practices fall outside of accepted parameters that may result in: services that are not considered medically necessary services or procedures not consistent with professional standards improper reimbursement or overuse 20

21 Fraudulent or Negligent Coding Practices There are two types of fraud: Civil Criminal These are defined by the Federal False Claims Act. Both Civil and Criminal types of fraud pertain to: listing services for reimbursement that were not actually performed, documented, or medically necessary. 21

22 Criminal or civil penalties Under what three circumstances are providers subject to civil or criminal penalties? 1. Having actual knowledge that something being submitted is wrong and not doing anything about it. 2. Reckless disregard of truth or falsifying of claims. 3. Acting in deliberate ignorance. 22

23 Compliance Launching of the Operation Restore Trust (ORT) Program in 1995 Designed to demonstrate a new partnership approach to finding and stopping fraud and waste in the Medicare/Medicaid programs Mission is to identify and penalize those who willfully defraud the Medicare/Medicaid programs Start of HIPAA in

24 Compliance Mandatory exclusions from participation in Medicare/Medicaid for ANY individual convicted of health care fraud Revision of criminal laws for false claims statements that include jail time of not more than five years or both jail time and fines 24

25 Compliance The OIG (Office of the Inspector General) has published several formats for implementing compliance plans in a variety of settings. The mere existence of a well-integrated and well-used compliance plan is a mitigating factor under federal sentencing guidelines. 25

26 Compliance What are the seven keys to an effective compliance plan? 1. Development of written policies and procedures 2. Designate a compliance officer 3. Conduct education and training 4. Effective communication 26

27 Compliance Auditing and monitoring Enforcement and Disciplinary Guidelines Corrective action and necessary reporting 27

28 What Does This Mean For You! ***Awareness is the key, education is the answer *** Having and keeping personal and professional ethics are the best ways to keeping yourself out of any trouble. 28

29 What Does This Mean For You! Don t code a service that is not supported by the medical documentation. Don t code a service simply because you were told by your provider, your manager or your supervisor to do so. Trust your gut, if it feels wrong, it probably is! 29

30 Who Can Report Fraud or Abuse? Absolutely anyone can report fraud or abuse. It is a very serious thing to do, however, so make sure you are not reporting someone for fraud or abuse because you have a grudge against them, don t like them, or worse because you were fired! 30

31 Who Can Report Fraud or Abuse? There are no restrictions about who can and should report fraud and abuse. Most payers now have areas on their websites that allow you to file a complaint. Don t expect instant gratification, however, there are literally hundreds of complaints that come into each office on a monthly basis. 31

32 Your Voice Counts! Get involved in furthering your education as a coder. Attend your monthly chapter meetings. Speak only in praise of our profession. Spread the word. 32

33 A Thief A thief by any other name is STILL a thief. Some thieves break into homes and steal material goods or sometimes priceless memories. Other thieves find unique ways to plunder businesses via the Web while others rob the public via our insurance plans. 33