Section 1: Introduction A. About This Course B. Learning Objectives Fraud, Waste, and Abuse for Section 2: Fraud, Waste, and Abuse A. Case Studies B. Defining Fraud, Waste, and Abuse C. The OIG D. The False Claims Act E. Responsibility to Report F. Review Section 3: Conclusion A. Summary B. Congratulations 2014 Relias Learning. All rights reserved. Page 1
About This Course Fraud, Waste, and Abuse for Section 1: Introduction One of the most important educational programs your home health agency is required to provide is one that ensures you gain a thorough understanding of healthcare fraud, waste, and abuse. Fraud, waste, and abuse remain a significant problem in federally funded healthcare programs and the recognition and reporting of suspected illegal practices will assist your agency with maintaining a high quality of care. Directed towards home health billing and field staff, this short, non-accredited course focuses on what constitutes fraud, waste, and abuse, and to whom you should report such activities. Learning Objectives After taking this course, you should be able to: 1. Recognize and report suspected fraud, waste, and abuse. 2. Explain the Mission of the Office of Inspector General. 3. Summarize the False Claims Act. 2014 Relias Learning. All rights reserved. Page 2
Case Studies Fraud, Waste, and Abuse for Section 2: Fraud, Waste, and Abuse Are you able to recognize fraud, waste, and abuse in your home health agency (HHA)? Are you familiar with how to report such activities? The following home health case studies are not inclusive of every detail in a home health environment but intended to cause reflection and critical thinking on the importance of recognizing fraud, waste, and abuse, and the steps to take when identifying such actions. You ll find the correct answers at the conclusion of each case study. Case Study 1 Betty, an RN who just completed her orientation with the agency, has just arrived at Ms. Garcia s house and is preparing for the visit by re-reading the instructions on the plan of care (POC). Ms. Garcia has a pressure ulcer on her right buttock and the POC instructs Betty to cleanse the wound with saline and cover with a hydrocolloid dressing. Betty realizes that she accidentally added the hydrogel gauze to her box of supplies instead of the hydrocolloid dressing. With her anxiety rising, Betty remembers something about a relationship between the two, and decides to grab the hydrogel gauze and uses it on Ms. Garcia s ulcer. After the dressing change, she signs off on the order. What is this an example of? Fraud Betty intentionally signed off on an order she did not provide. Waste Betty intentionally used a supply (dressing) she did not need. Abuse Betty intentionally signed off on an order that was not medically necessary. Feedback: Continue with the case study for the answer. A few days later, Andy, an RN who has been with the agency for over five years, is assigned to visit Ms. Garcia due to her complaint of increasing pain in her ulcer area. As Andy is accessing the pressure ulcer site, he realizes that the incorrect dressing was used, and though the dressing itself may or may not be attributed to Ms. Garcia s pain, he reviews the POC to confirm his suspicions. What should Andy do regarding his suspicions? Nothing; Andy should ignore the incident. Talk with Betty about the incident. Report the incident to his manager or compliance officer. Case Study Answer: Betty knowingly signed off on an order she did not provide (fraudulent activity) AND she practiced outside her professional scope of practice (professional illegal activity). Though Andy does not know whether Betty intentionally used the incorrect dressing, he does know that she signed off on an order she did not provide. If Betty had contacted the physician to inquire about the hydrogel dressing, she may have received the approval for such a dressing, or 2014 Relias Learning. All rights reserved. Page 3
Fraud, Waste, and Abuse for a suitable alternative. Discussing the incident with Betty is not the best action to take as Betty may become angry, defensive, or plead for secrecy all actions that will place Andy in an uncomfortable and potentially illegal situation. Andy has a duty, both professionally and by law, to relay his concerns objectively to either his supervisor or the compliance officer. Case Study 2 Trisha, one of your co-workers and a well-respected expert on home health coding, has confided in you that a physician is behaving suspiciously, Dr. Gary sends us piles of billed services every so often and we have to focus on submitting those claims or our manager becomes very upset. I think the doctor harasses her cause she hates to take his phone calls. Personally, I think he is up to something, but that s not my problem and I m not going to get involved in this mess. What should you do? Nothing, this is none of your business. Encourage Trisha to report her suspicions to the compliance officer. Report the incident to your compliance officer. Continue with the case study for the answer. Due to Trisha s description, what is the physician most likely practicing? Fraud the physician is intentionally billing for services he did not provide. Waste the physician is intentionally billing for extra supplies he does not need. Abuse the physician is intentionally charging for medically unnecessary services. Case Study Answer: This case is a real-life scenario of murky waters. You have no idea whether the physician is doing anything that constitutes fraud, waste, and/or abuse, so each answer chosen may or may not be correct. However, whether or not YOU know the physician is doing anything unethical or illegal, if Trisha does not intend to report her concerns, you must, or you may ALL be in legal trouble if the physician s activities are exposed and found to be illegal. Encouraging Trisha to report her suspicions after she stated she did not want to get involved is risky, as she may share your concern with your manager, who may or may not be collaborating with the physician s activities, or she may become resentful and angry towards you. There are real-life scenarios similar to this case study in which reporting anyone seems a bit drastic, or places you in a very uncomfortable situation; however, you must remember that ignoring such activities is against the law and not to be taken lightly. A good alternative for this type of scenario is to utilize your compliance officer s hotline to ensure you re doing what s expected of you, and still remain anonymous. The compliance officer is now responsible for digging into the report and determine just what the physician is up to, if anything. Defining Fraud, Waste, and Abuse According to the Centers for Medicare and Medicaid Services (CMS, 2012), fraud is creating 2014 Relias Learning. All rights reserved. Page 4
Fraud, Waste, and Abuse for false statements or representations in order to receive a benefit or payment that would otherwise not exist. Examples of healthcare FRAUD are when a physician bills Medicare for an exam that was never provided, or intentionally uses the wrong diagnosis code on the medical bill in order to receive more money in reimbursement. An example of healthcare staff committing fraud is when a nurse fills out an assessment form for an individual receiving home health care yet never completed the assessment. WASTE is the overutilization of services, or other practices that, directly or indirectly result in unnecessary costs (CMS, 2013). Examples of healthcare waste include when a provider writes an order for a brand name medication when a generic is available and appropriate, or when a nurse opens an excessive amount of sterile supplies for a non-complicated dressing change. Examples of healthcare ABUSE are when a provider or organization charges excessively for supplies, or submits claims for services that were not medically necessary. Both fraud and abuse can expose providers and healthcare organizations to criminal and civil liability. Waste is generally not a criminal action but potentially costs the government (and thus taxpayers) millions every year. An important note: The educational focus for healthcare professionals is not to necessarily know the matching definitions of fraud, waste, and abuse, but to effectively recognize and report potentially unethical or illegal practices. The OIG Detroit Home Health Agency Office Manager Sentenced for Her Role in $5.8 Million Medicare Fraud Scheme. FOR IMMEDIATE RELEASE - The office manager of a Detroit-area home health agency was sentenced today to serve 46 months in prison for her role in a $5.8 million Medicare fraud scheme. According to evidence presented at trial, the defendant and her co-conspirators caused the submission of false and fraudulent claims to Medicare that purported to provide skilled nursing and physical therapy services to Medicare beneficiaries in the greater Detroit area. Source: OIG, 2014b Unfortunately, the news article you just read is factual; highlighting the fact that Medicare fraud and abuse continues to be a significant problem in the United States. Created to investigate, address, and prevent fraud and abuse in federally funded healthcare programs, the Mission of the OIG is to protect the integrity of Department of Health and Human Services programs as well as the health and welfare of program beneficiaries (2014a). The oversight includes the identification of inappropriate payment for claim errors. The OIG (2012) found that Medicare inappropriately paid HHAs $5 million in 2010, with three specific errors in claims recognized: 2014 Relias Learning. All rights reserved. Page 5
Fraud, Waste, and Abuse for 1. Overlapping claims for inpatient hospital stays 2. Overlapping claims for skilled nursing facility stays 3. Claims submitted for services after the death of beneficiaries CMS prioritizes claims submitted for beneficiary inpatient hospital or skilled nursing stays over HHA claims. If an HHA submits a claim that overlaps with the dates of inpatient hospital or skilled nursing facility dates, it will result in denial. Exceptions include beneficiary services that occur the same day of discharge or admittance. Claims submitted for beneficiary services whose death occurred within an episode are appropriate. Inappropriate claims are those submitted for dates of services after the death of a beneficiary. In another analysis, the OIG (2012) found that HHAs submitted 22 percent of claims in error due to unnecessary services or inaccurate codes, resulting in improper payments of over $400 million. HHAs are responsible for determining that the submission of claims are appropriate, meet the requirements of a qualifying service, and are medically reasonable and necessary. The False Claims Act The False Claims Act is a strict federal law that prohibits anyone, including HHAs, from knowingly using false records, or submitting false claims, to federal or state healthcare programs such as Medicare. Knowing as defined by the FCA means not only actual knowledge, but also deliberately ignoring something inappropriate that is going on, e.g. apathy (who cares?), and reckless disregard of the truth. Someone who submits a false claim without knowing the claim is false does not violate the FCA (U.S. Department of Justice, 2011). The FCA provides protection for employees or whistleblowers who report fraudulent and abusive activities to the OIG or CMS. Retaliation is strictly prohibited. Responsibility to Report If you recognize something inappropriate going on, to whom do you report your concerns? According to federal regulations, your agency must have a compliance program in place. Report your concerns to either your manager, or if you prefer, the designated compliance officer. The compliance officer responds to suspected or detected compliance violations, immediately investigates the violations, and takes the appropriate action to address and rectify the violation, taking steps to determine why the violation occurred to ensure it does not happen again. Many officers have a toll-free number, called a hotline, for questions or concerns regarding suspected fraud and abuse. Anyone who uses the hotline will remain anonymous in order to encourage reporting of potentially unethical or illegal action. In addition to turning to your manager or compliance officer, both the CMS and the OIG have hotlines to report suspected Medicare fraud and abuse. Refer to the Resources section at the top right for more information. 2014 Relias Learning. All rights reserved. Page 6
Fraud, Waste, and Abuse for Review Introduction: Here s a flash card review of the content in this section. Viewed cards will display a check mark. Click Next when you finish viewing all the cards. Q1: Fraud, waste, and abuse. Which of the three may expose providers and healthcare organizations to criminal and civil liability? A1: Fraud and abuse. Waste is generally not a criminal action but potentially costs the government (and thus taxpayers) millions every year. Q2: True or False. CMS prioritize claims submitted for beneficiary inpatient hospital or skilled nursing stays over HHA claims. A2: True. If an HHA submits a claim that overlaps with the dates of inpatient hospital or skilled nursing facility dates, it will result in denial. Exceptions include beneficiary services that occur the same day of discharge or admittance. Q3: What is the mission of the Office of Inspector General (OIG)? A3: To protect the integrity of the HHS programs, and the health and welfare of program beneficiaries. 2014 Relias Learning. All rights reserved. Page 7
Summary Fraud, Waste, and Abuse for Section 3: Conclusion Medicare fraud, waste, and abuse remain a significant problem in federally funded healthcare programs. Everyone in your agency, or associated with your agency, is an important participant in recognizing, reporting, and preventing fraud, waste, and abuse. Agencies are held responsible for ensuring all claims submitted are appropriate, meet the requirements of a qualifying service, and are medically reasonable and necessary, and though agencies must have standards in place to quickly identify and report potential incidences of fraud, waste, and abuse, according to the law, so do you. Now that you have finished reviewing the course content, you should be able to: 1. Recognize and report suspected fraud, waste, and abuse. 2. Explain the mission of the Office of Inspector General. 3. Summarize the False Claims Act. Congratulations! You have finished reviewing the course content. 2014 Relias Learning. All rights reserved. Page 8