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7-2005TUMG Compliance

Fraud and AbuseAvoiding Pitfalls

Compliance Education and Training

One Compliance Credit earned for viewing presentation and completing

quiz

Tulane University Medical Group

Read Before Proceeding

Physicians and Staff may earn one compliance credit by viewing this slide show, completing the assessment, and faxing the assessment to the

University Privacy and Contracting Office: 504-988-7777

This presentation may be viewed for compliance credit only once in a fiscal year

(July 1 - June 30).

To check how many compliance credits you have and to see which training sessions you have

completed, contact the University Privacy and Contracting Office at

504-988-7739

It is the policy of TUMG to provide healthcare services that are in compliance

with all state and federal laws governing its operations and consistent with the highest

standards of business and professional ethics. Education for all TUMG physicians is

an essential step in ensuring the ongoing success of compliance efforts.

Purpose of Presentation

To provide physicians and staff with Definitions and examples of fraud and abuse An overview of resources to assist providers

in appropriately coding services rendered

Why does CMS (Center for Medicaid and Medicare Services) put such an emphasis on Fraud & Abuse?

Complexity of the program Expense

COMPLEXITY OF THE PROGRAM

The expansion of the Medicare and Medicaid programs (including the prescription drug option) and the complexity of the programs make it difficult to adequately monitor.

Physicians are expected to “Know the Rules” and properly apply them to their billing.

$$ EXPENSE $$ Medicare spends

approx. $40 billion per year for medical services In recent years, billing

and reimbursement for some services has greatly increased

The OIG Work Plan often targets those medical services where reimbursement exceeds budget projections

The Medicare Program is under increasing pressure to remain solvent as “baby boomers” move into Medicare-eligible age range.

The prescription benefit will add more cost to the program

But it’s not just Medicare that investigates and prosecutes billing fraud and abuse…

A common billing myth is that providers should only be concerned with bills submitted to Medicare.

All payors, whether governmental or commercial, have billing guidelines that must be followed.

Louisiana Medicaid has billing guidelines that are different from those of Medicare and/or commercial payors.

It is important that providers understand and correctly apply the appropriate billing guidelines.

A note about LA Medicaid…

Physicians are responsible for their billing

Physicians are responsible for understanding and appropriately applying billing guidelines for the services they provide.

Providers should take an interest in their billing and take care to avoid billing practices that could be construed as either fraud or abuse.

Some Sobering Facts OIG exclusion database through

August 2006 (checked 9/13/06) lists 813 businesses/ private citizens in Louisiana excluded due to fraudulent practices (up from 742 in 7/2005)

(source: OIG exclusion database)

Some Sobering Facts: OIG 2004 Annual Report

• During 2004, the Federal Government won or negotiated approximately $605 million in judgments and settlements.

• U.S. Attorneys’ Offices opened 1,002 new criminal health care fraud investigations involving 1,685 potential defendants.

• A total of 459 defendants were convicted for health care fraud-related crimes during the year.

• The Department of Justice opened 868 new civil health care fraud investigations, and had 1,362 open civil health care fraud investigations

Source: Annual Report of the Attorney General and the Secretary Detailing Expenditures and Revenues Under the Health Care Fraud and Abuse Control Program For Fiscal Year 2003

It is a federal crime to defraud

the U.S. Government or any of

its programs and can result in

imprisonment, fine or both.

Fraud and Abuse Penalties

Civil Monetary Penalties (CMP)

Criminal Sanctions (jail, exclusion from the Medicare/ Medicaid program)

What entities investigate and prosecute Fraud and Abuse?

Department of Health and Human Services (DHHS)

Department of Justice (DOJ) Office of the Inspector General (OIG) FBI Medicaid Fraud Units

What laws/acts establish the framework for investigation &

prosecution?

HIPAA (Health Insurance Portability and Accountability Act (Title II)

Federal False Claims Act Stark Legislation (Phases I and II) “Anti-kickback statute” (part of the

Medicare/Medicaid statute) Mail Fraud Sarbanes-Oxley

Definition of Fraud Intentional. Deliberate deception.

Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.

Source: Medicare Resident and New Physician Guide, page 124

Examples of Fraud

Billing for services not furnished and/or supplies that were not provided

Offering incentives to Medicare patients that are not offered to non-Medicare patients (e.g., routinely waiving or discounting the Medicare deductible and/or co-insurance amounts)

Examples of Fraud Offering, soliciting, or

accepting bribes, kickbacks, or discounts for referral of patients or orders of services or items

Falsifying information on applications, medical records, billing statements, and/or cost reports or any statement filed with the government

Misrepresenting excluded services as medically necessary by using inappropriate procedure or diagnosis codes

Definition of Abuse Unintentional. Occasional. Practices that either directly or indirectly

result in unnecessary costs to the Medicare program.

Abuse may appear similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully and intentionally.

Source: Medicare Resident & New Physician Guide, page 124

Abuse can escalate into Fraud

Repeated billing errors that point to a BILLING PATTERN may be construed as a fraudulent billing practice

Occasional/unintentional misinterpretation of billing guidelines may be considered abuse; repeated, routine billing practices that do not comply with billing guidelines may be construed as fraudulent

Examples of Abuse:

Providing medically unnecessary services

Providing services that do not meet professionally recognized standards.

Violating the participating physician, supplier agreement with Medicare or Medicaid

Charging in excess for services or supplies

Source: Medicare Resident and New Physician Guide, page 125

Avoiding pitfalls KNOW THE RULES!

All providers should be familiar with the billing guidelines for Medicare, Medicaid and Commercial payors

Avoiding pitfalls Ignorance of billing guidelines is not

considered a defense against a fraud or abuse allegation.

The contractual agreements between providers and payors clearly state the provider’s responsibility to understand and appropriately apply billing rules.

Recent Fraud Cases December 2005 –

… a dentist was sentenced to 63 months in prison and ordered to pay $827,000 in restitution and a $20,000 fine; he was found guilty in a jury trial on charges of mail fraud and health care fraud. The dentist performed unnecessary dental procedures on patients and billed for services not performed, or not performed as indicated.

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/05/1205.html

Recent Fraud Cases March 2006 –

… a dermatologist was sentenced to 20 years in prison and ordered to pay $888,888 in restitution for unlawfully distributing prescription narcotic drugs and health care fraud… a jury found that the dermatologist’s conspiracy to distribute prescription narcotics resulted in the death of a patient. The patient, who died from an overdose of Dilaudid, saw the dermatologist approximately 24 times each month… the patient allowed the dermatologist to submit the fraudulent bills, in exchange for prescriptions for controlled substances and monthly cash payments of $700.

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/06/0306.html

Recent Fraud Cases February 2006 – Virginia

… a podiatrist was sentenced to one year and one day in prison for mail fraud. The podiatrist billed for procedures performed at a surgery center when, in fact, the services performed were routine, and performed in the office. The address of the surgery center was actually a mailbox rental business located next to his office. Through his billing scheme, the podiatrist was reimbursed for facility-related charges such as pre-op and post-op rooms.

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/06/0206.html

7-2005TUMG Compliance

The More You Know...Resources for Providers

CMS Sources - E/M Services

Medicare Teaching Physician Rule http://www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf

Medicare 1995 documentation guidelines http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf

Medicare 1997 documentation guidelines http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

U.S. Government Website: http://www.cms.hhs.gov

LAMedicare Website: http://www.lamedicare.com/

Medicare Resources

Medicare Resources You may also be interested in:

http://www.trispan.com/factsheets/FraudAlert.pdf A concise, one-page reference that lists examples of

fraud and abuse.

http://www.medicare.gov/FraudAbuse/Tips.asp This reference sheet targets Medicare recipients. A list

of questionable activities are listed, and recipients are told “You should be suspicious if the provider tells you that…”

Know who to contact: M. Reina, Senior Director, TUMG

Business Services mreina@tulane.edu

Compliance Reporting Hotline: 504-988-5142

To Earn Compliance Credit:Complete and Sign the “Fraud

and Abuse” Coding QuizFax to: 504-988-7777

End of Presentation