FRAUD, ABUSE & COMPLIANCE

An intentional deception or misrepresentation made by an individual who knows that the false information reported could result in a benefit to himself/herself or another person.

Billing for services or supplies not provided

Duplicate billing- SUBMIT CLAIM MORE THAN ONCE. Investigate why a claim has not been paid etc. prior to billing again. If you bill more than once falsely, you can violate the False Claims Act.

See page 197 in your book.

Upcoding- When you bill for a service higher than what is documented in the medical record. Example: Dr see’s established pt for 15 mins. Code is 99212…..but you turn in a claim that shows 99214- which says pt was there for 45 mins etc.

Upcoding is illegal and fraudulent. Any provider who intentionally upcodes is breaking the law.

As patients we might think it doesn't matter to us because it's the insurer who is paying for it. However, upcoding costs all of us money, both as taxpayers and as premium payers. When a Medicare or Medicaid patient is upcoded, then we all pay for it. If a private insurer receives an upcoded bill, then premiums go

up for everyone who has that insurance. Read more at:

http://patients.about.com/od/costsconsumerism/a/upcoding.htm

HOT NEWS: http://www.lifehealthpro.com/2012/02/08/hospitals-to-pay-

12m-to-settle-medicare-upcoding-c

Unbundling- billing should include the entire procedure, not broken into parts to receive more $$.

Example: Fragmenting one service into component parts and coding each component part as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach, is inappropriate.

* Reporting separate codes for related services when one comprehensive code includes all related services. An example of this type is coding a total abdominal hysterectomy with or without removal of tubes, with or without removal of ovaries (CPT code 58150) plus salpingectomy (CPT code 58700) plus oophorectomy (CPT code 58940) rather than using the comprehensive CPT code 58150 for all three related services.

USE THE CCI– CORRECT CODING INITIATIVE MANUAL TO PREVENT UNBUNDLING.

AMA= American Medical Association- they classify medical problems as; urgent, non urgent and emergent.

The practice of omitting certain codes on a superbill is called: Code steering.

An incident or practice not consistent with sound medical, business, or fiscal practices, such as providing medically unnecessary care or care that does not meet the standards of care.

Examples you can think of?

OIG– OFFICE OF INSPECTOR GENERAL- PAGE 196Federal agency- http://oig.hhs.gov/They inspect, make recommendations and decide if a Dr./office is guilty. They conduct audits with Medicare and Medicaid.Whistleblowing- reporting fraud and/or abuse to OIG. Employees cannot be terminated for whistleblowing if they are correct in their accusation of fraud.OIG sends out a plan every year ( ANNUALLY) to offices of what they look for……..offices should get copy each year, and Om ensures practice not guilty of anything on the list.

The Fraud and Abuse Control Program was established by the government under:

HR3103 Subtitle A The first fraud alert was issued in: 1988 Under the Beneficiary Incentive Program, beneficiaries receive at least

which of the following dollar amounts for reporting fraud? $100- reporting Fraud to OIG.

The Incentive Reward Program has a cap of: $1000 or 10%. The Incentive Reward Program (IRP) was established to

pay an incentive reward to individuals who provide information on Medicare fraud and abuse or other sanctionable activities. This rule adds a new Subpart E to 42 CFR 420 (“Program Integrity: Medicare”)

NOT a physician practice risk area according to the OIG?

COLLECTION AGENCIES CREDIT BALANCE TO A PATIENT.

Which act provides for overtime worked? Fair Labor Standards Act Which act was designed to protect the

handicapped against discrimination? Vocational Rehabilitation Act Which act protects employees from

benefits discrimination? Older Workers Benefit Protection Act The Patient Self-Determination Act came

into effect in which year? 1991