DEVELOPING HEALTHCARE FRAUD,WASTE & ABUSE FOR COMPLIANCE

BY MODUPE SARRATT

HCAD 640 9041

FIN MGMT FOR HEALTH CARE ORGS

UNIVERSITY OF MARYLAND UNIVERSITY COLLEGE

A Cited Case for Health Care Fraud is United States v. Halper

Respondent Irwin Halper worked as manager of New City Medical Laboratories, Inc.,

a company which provided medical service in New York City for patients eligible for

benefits under the federal Medicare program. In that capacity, Halper submitted to

Blue Cross and Blue Shield of Greater New York, a fiscal intermediary for Medicare,

65 separate false claims for reimbursement for service rendered. Specifically, on 65

occasions during 1982 and 1983, Halper mischaracterized the medical service

performed by New City, demanding reimbursement at the rate of $12 per claim

when the actual service rendered entitled New City to only $3 per claim. Duped by

these misrepresentations, Blue Cross overpaid New City a total of $585; Blue Cross

passed these overcharges along to the Federal Government.

The Government became aware of Halper's actions and in April 1985 it indicted him

on 65 counts of violating the criminal false-claims statute, 18 U. S. C. § 28

-- (1989).

Fraud, Waste and Abuse Compliance Policy

Healthcare Fraud, Waste and Abuse is estimated to add from 3% to 10% to all healthcare

spending. Unchecked fraud and abuse in our system can cost taxpayers billions of dollars each

year and divert critical healthcare dollars away from those who need the care. Protecting

government dollars used for healthcare is an important part of all of our jobs.

Definitions:

FRAUD

– Is a false statement - made or submitted by an individual or entity - who knows

that the statement is false, and knows that the false statement could result in

some otherwise unauthorized benefit to the individual or entity. These false

statements could be verbal or written.

WASTE

– Generally means over-use of services, or other practices that result in

unnecessary costs. In most cases, waste is not considered caused by reckless

actions but rather the misuse of resources

ABUSE

– Generally refers to provider, contractor or member practices that are inconsistent

with sound business, financial or medical practices; and that cause unnecessary

costs to the healthcare system.

--Reference:2016 SHL Provider Summary Guide

ENFORCING THE STANDARD FOR NO FRAUD, WASTE, OR ABUSE IS HEALTHCARE IS A HUMAN RIGHT

Healthcare is a human right

to medical services for:

Health Information

Medical Information

Medical Treatment

Health care services

Medical Charges

Insurance Payment for

health care & medical

care services.

MUST READ: DOUBLE CLICK THE ARTICLE

ALERT: TO THE LAW FOR COMPLIANCE PROGRAM

HOW DOES A PRACTICE GET STARTED?

B. The Compliance Review or "Legal Audit"

The foundation for a truly "effective" compliance plan is developed

before the compliance program

itself is designed and implemented. A rigorous "legal audit" or

compliance review accomplishes this

objective. The legal audit is nothing more than a comprehensive

internal investigation of the provider's

operations, generally focused on one or more targeted areas. The

purpose of the compliance review is to

ascertain whether the provider's current practices and procedures

conform with all pertinent legal

requirements. Such reviews particularly focus upon detecting any

potential violations of the Federal

Health Care Anti-kickback law, 42 U.S.C. § 1320a-7b(b), the civil

False Claims Act, 31 U.S.C. §§

3729-33, and pertinent regulations.

HEALTHCARE FRAUD COMPLIANCE PROGRAM

A. Healthcare Fraud Compliance Program is a federal

government law for the False Claims Act, that provide

the list of fraud under which its can recover damages plus

a penalty that ranges between $5,000 and $10,000 for

each fraudulent request for healthcare reimbursement.

(1) Federal criminal prosecutors can allege or charge for

kickbacks/bribes,

(2) mail fraud,

(3) making false statements in connection with claims

submitted to Medicare or state health programs,

(4) and conspiracies to defraud the government

(5) just to name a few pertinent criminal statutes.

Moreover, providers have come to dread a new player in

the enforcement game: qui tam law suits filed by

"whistleblowers" on behalf of the government who will

ultimately share as much as 30% of an

---Reference Fox & Clark 2000

AVOID FRAUD FOR ANTI-KICKBACK REGULATION

Reason to avoid Fraud is simple for retaliation of anti-kickback regulations. According to Schencker (2016), the price to pay outweighed the crime. The article for the penalties of fraud indicated this:

Fraud penalties for healthcare providers and others will soon likely double, according to an interim final rule published Thursday in the Federal Register. Penalties for each false claim submitted to a government program, such as Medicare, will rise to a minimum of $10,781 from a current minimum of $5,500 under the False Claims Act. The maximum would rise to $21,563 per claim from a current maximum of $11,000. It's not unusual for thousands of claims to be at issue in a False Claims Act case, leading to the possibility of total potential penalties in the millions and even billions of dollars.

According to the rule, penalties for violations of the Anti-Kickback law will also rise from $11,000 to $21,563.

The avoid fraud requires a due diligence in the delegation of authority; because fraud is

tangled with the executives, who are entrusted to have the authority to make decisions

ARTICLE CITED FOR WRITTEN POLICIES, PROCEDURES, & STANDARD OF CONDUCT

DOUBLE CLICK THE ARTICLE

FOR READING AFTER

ATTENDING THE TRAINING

IN SLIDE 16

HEALTHCARE FOR COMPLIANCE REQUIRE A VISION FOR HEALTH & MEDICAL OPERATION

VISION

Treat to Cure for Practicing Medicine is the relationship between the Providers, the Patients, and the method of Payments:

Healthcare is Human Right. To be treated for an illness. To be free from indebted to medical care or health care is receiving a quality treatment for a reasonable price.

To avoid fraud, waste or abuse; providers & patients must compromise & compliance to ethics & what is reasonable & fair for medical operation of rendering health care services & medical services

OPERATION

For the delivery of health and medical services & for Compliance to the policies is the Patient Statements for Care.

To determine what is necessary, affordable & what to charge for providing care by the provider

Would require the analysis for eliminating waste, to avoid fraud, & with removing any notion for possible abuse.

(Provider should note that a waste can be from patient requesting for unnecessary procedure & vise versa for provider ordering unnecessary procedure)

While addressing the challenges for payment is applying the appropriate steps for complying to policy

With the diligent to report possible mistake or susceptible conduct of fraud

The view is an obstructer will be caught for discipline, never think of getting away with fraud or misconduct

for an individual undertaking a corrective action to change a wrong view or a wrong thought for an idea

When it comes to being caught for a fraud, a waste, or an abuse of a system, there is no excuse.

7 SUGGESTIONS: FOR COMPLIANCE TO POLICIES

1. Affordable: reasonably priced to be inexpensive

2. Serviceable: in working order to fulfilling operational functions adequately

3. Flexible: capable of adjusting without breaking or suffering is ready and able to change so as to adapt to

different circumstances “You can save money if you’re flexible about where your room is located” is able to

save money when patient know what to buy for health care.

4. Multiple: is having options for variations of several elements associated with how services can be rendered

or adjusted to meet the patients ability for affordable care

5. Controllable: is statistics of comparison for checking the results of the alternatives to direct a situation for

manageable (if is not controllable, then is manageable with adjustable to patient ability to afford health

care.

6. Detectable: is capability to discover what can be done to solve a problem by identify the presence or

existence of an issue to expose the real or hidden nature of something is wrong to request or call for an

investigation

7. Transferable: is typical of financial assets, liabilities or legal right that is able to be transferred for auditing,

is initiated for transparency of accounting and the financial record of Cure Med.

7 SUGGESTIONS: FOR DELIVERY OF SERVICES

1. Expedite: is the protocol to process information that can be accomplished quickly.

2. Ensure: is making certain that information expedite occurs to be the case. To ensure against any notion that information may be fraudulent is making sure that a problem cannot occur with information provided.

3. Enhance: is to intensify, increase or further the quality of value information to the extent there is no refutability or falsifiability

4. Eliminate: is completely remove any doubt for the policy that would eliminate inflation in the course of providing health care. A guarantee for what a patient bought for healthcare service is what he or she will get from the rendering of health care service.

5. Improved: is make or becoming better with the used of healthcare information technologies.

6. Increase: is the becoming of greater health service beyond the expectation of requirement. The patient can make a change in the sales and profit margins for health insurance. Patient can demand to lower the price of premium to increase participation in buying health insurance.

7. Minimize: is reducing the unwanted or unpleasant of healthcare costs to keep down the cost for reducing fraud

Understanding that FWA is an Individual Liability

Must Watch to know why: Double Click NASP

ENFORCING STANDARDS WITH WELL-PUBLICIZED GUIDELINES

Relationship of Patients & Providers

Explained with procedures & management for charges

Correlation of Policies & Third Parties

Explained with filling out the Claim form for payments

Due Diligence in the Delegation of Authority is Understanding Value-Based Healthcare

▪ By Cost for step 1

▪ By Charge for step 2

▪ By Payment for step 3

▪ For adapting to health care policies and adjusting to the third parties protocols are the requisitions to examining step 2 & step 3 for the Value-Based Healthcare.

Step 1: Cost

•To providers: is the expenses incurred to deliver care services to the patients

•To payers: the amount of health care coverage pay to the providers for services rendered by the third party for patient health insurance

•To patients: the amount pay out-of-pocket for health care services.

Step 2: Charge or Price

•The amount asked by a provider for a health care good or service, which appears on patient medical and health insurance claim (CMS-1500 Form)

•Providers price or charge are fixed for service rendered. However, charges are subject to evaluation of services for customary, for the alternative, or if the service is requested, and whether the service is necessary.

Step 3: Payment or the type of reimbursement

•A payment made by the third party to a provider for his or her services. That may be an amount for every services delivered as “fee-for-service” in solo medical practice and Specialist practice.

•A payment made to the hospital for each day a patient is hospitalized for service is per diem for “fee-for-stay” for each day that a patient is in the hospital plus

•A payment for each episode of diagnosing patient for a treatment, such as, while in the hospital bed a patient call for pain medicine or for nurse attention is known for “diagnosis-relate group charges or DRG” plus

•Payment for patient under the hospital care known as “capitation” because a patient in the hospital is considered to be under the hospital care regardless whether the patient is receiving treatment or not, the charges is every thing else included for monitoring patient while he or she is still in hospital.

---- Reference: Arora et al (2015).The challenge of understanding health care costs and charges.

The Centers for Medicare & Medicaid Services

(“CMS”) modified certain rules and regulations of

the Medicare Advantage and the Part D programs

that state that a contractor’s compliance plan

must include training.

DOUBLE CLICK PRESENTING FOR ATTENDING THE COLLABORATION TRAINING FOR FWA & COMPLIANCE

The Five Questions

1) WHAT IS A HEALTHCARE FRAUD COMPLIANCE PROGRAM?

2) HOW CAN A PROVIDER DESIGN AND IMPLMENT ONE?

3) WHY ARE COMPLIANCE PLANS ESSENTIAL?

4) WHAT ARE THE ELEMENTS OF A COMPLIANCE PROGRAM?

5) HOW DOES A PRACTICE GET STARTED?

PRESENTING

THE TRAINING FOR FRAUD,

WASTE & ABUSE.

DEVELOPED BY THE

CENTER FOR MEDICARE &

MEDICAID SERVICES

References

Arora, V., Moriates, C. & Shah, N. (2015). The challenge of understanding health care costs and charges. AMA Journal of Ethics, 17 (11): 1046-

1052. doi: 10.1001/journalofethics.2015.17.11.stas1-1511

Centers for Medicare & Medicaid Services. (2015). Medicare fraud & abuse: Prevention, detection, and reporting.

Fox, A., & Clark, R. H. (2000). What Is A Healthcare Fraud Compliance Program And How Can A Provider Design And Implement One?

Retrieved from file:///C:/Users/Admin/Downloads/Healthcare-Fraud-Compliance-Program%20(2).pdf

National Health Care Fraud Takedown Results (2016- https://t.co/LQk9OJpzKN pic.twitter.com/HMVFxvFrgd

— Justice Department (@TheJusticeDept) June 22, 2016

Schencker, L. (2016 June 30). Fraud, anti-kickback penalties to double.

Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639989

Sparrow, M. K. (1996). Health care fraud control: understanding the challenge. JOURNAL OF INSURANCE MEDICINE-NEW YORK-, 28, 86-

96.

United States v. Halper, 490 U.S. 435, 109 S. Ct. 1892, 104 L. Ed. 2d 487 (1989).

Retrieved from https://scholar.google.com/scholar_case?case=885240111461112288&q=MEDICARE+FRAUD+%26+ABU

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