Health Program Overview Fraud, abuse and waste in Medicaid cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services. Not only do fraudulent and abusive practices increase the cost of Medicaid without adding value — they increase risk and potential harm to patients who are exposed to unnecessary procedures. While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments.
It is projected that fraud and abuse account for between 3 to 15 percent of annual expenditures for healthcare in the United States.
Chamber of Commerce Report places it at 15 percent. To further fight the rising incidence of fraud and abuse, in the Attorney General announced that tracking fraud and abuse would be a top priority for the Department of Justice.
What Is Healthcare Fraud?
Abuse is similar to fraud, except that the investigator cannot establish the act was committed knowingly, willfully, and intentionally. Solutions to Fraud and Abuse Under the above definitions, it is impossible to delineate between fraud and abuse on the basis of evaluating a single case or record.
In order to prove fraud, the government must prove that the acts were performed knowingly, willfully, and intentionally. To prove fraud occurred rather than abuse, the upcoding or miscoding of an event must occur over time and across a large number of patients.
For example, in the case of the Florida dermatologist noted above, fraud occurred over a period of six years, 3, false procedures, and patients. From our review of the literature, the following four solutions to identifying and reducing fraud and abuse are suggested: Accurate medical record documentation is essential not only in addressing issues of fraud and abuse but in providing patients with quality care.
One study found that undercoding was three times more likely to occur than overcoding. Educational and training programs focused on CPT codes should emphasize the importance of documentation to support time spent examining the patient. Each level requires more specification in documentation to justify reimbursement levels based on the expected amount of time the physician spends with the patient to perform services required.
For example, a Level 1 code is usually used for patients with minor problems, where the history and examination are focused and medical decision making is straightforward.
Typically, for a Level 1 code, the physician would spend approximately 10 minutes face-to-face with the patient. For a Level 3 codethe presenting problems are low to moderate in severity, and the history and examination is more detailed; however, the medical decision making is likely to be of low complexity.
Here the physician would typically spend approximately 30 minutes face-to-face with the patient. To avoid charges of fraud or abuse, the physician must justify through documentation the additional 20 minutes spent in face-to-face care to receive the higher reimbursement level.
Implementation of fraud and abuse education and training programs may be facilitated through establishing corporate or staff coding committees to create standards and protocols e.
This committee would consist of a compliance officer, health information management HIM staff, physicians, nurses, and financial administrators.
The coding committee would establish guidelines for staff concerning proper documentation for level of services provided, establish enterprise-wide training guidelines, perform audits to verify accuracy, and serve as a communication liaison between coders and organizational administration.
The coding committee would facilitate site review of training programs focused on teaching ethical principles such as a code of ethics and values to providers, staff, and healthcare administrators. In addition to establishing a coding committee, it is important to bring in external experts to provide an unbiased evaluation of guidelines and processes.
Training grassroots coders through externally sponsored programs also allows HIM coders to better identify gaps in documentation related to appropriate codes. Currently, there are two key financial issues driving CAC adoption:Healthcare Fraud and Abuse Archives In Texas, a supplier of durable medical equipment was found guilty of five counts of healthcare fraud due to submission of false claims to Medicare.
The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.
Whether you have employer-sponsored health insurance or you purchase your own insurance policy, health care fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage.
Indeed, according to the ACFE’s Report to the Nation: Occupational Fraud and Abuse, an estimated $ billion, or about $4, per employee, was lost last year as a result of on-the-job fraud and abuse. Although financial statement fraud was the most costly, with a median loss of $ million per occurrence, about 95% of all occupational fraud incidents actually involved asset misappropriation .
Detecting and Preventing Fraud, Waste and Abuse MVP Compliance Office 1 Overview It is the policy of MVP Health Care, Inc. and its affiliates (collectively referred to as the.
Fraud, Waste and Abuse Training. standards of conduct and ethical rules of behavior. As an employee of ValueOptions, you are required by Federal law to In order to detect fraud, waste and abuse.
you need to know the Law. 11 Key Terms Term Definition Criminal Fraud. Medicare Fraud & Abuse: Prevention, Detection, and Reporting MLN Booklet Page 5 of 16 ICN September Program integrity encompasses a range of activities targeting various causes of improper payments.