Fraud, Waste and Abuse Issues in the Healthcare

what is the definition of fraud?

an intentional deception or intentional misrepresentation that a person makes to gain a benefit for which that person is not entitled

5 examples of fraud in healthcare =

- Knowingly billing for services that were not furnished

- Knowingly altering claim forms to receive a higher payment amount (upcoding)

- Falsifying documentation (treatment dates, embellishing what you did to garner higher payment)

- Using unlicensed individuals to provide services

- Referral kickbacks and/or self-referrals (financial interest)

what is abuse in healthcare?

payment for items or services when there is no legal entitlement to that payment, and the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment

4 examples of abuse in healthcare =

- Misusing codes on a claim

- Charging excessively for services or supplies

- Billing for services that were not medically necessary

- Unbundling and billing individual components of a service instead of the all-inclusive procedure

what is waste in healthcare?

overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system

- misuse of resources

- deficient management, practices, or controls can result in waste

- Given the complexity of payment systems, waste is much more common than fraud or abuse

3 examples of waste in healthcare =

- Spending on services that lack evidence of producing better outcomes compared with lessexpensive alternatives

- Failures of care coordination that result in unnecessary hospital readmissions, avoidable complications, and declines in functional status

- Ordering unnecessary tests to guard against liability in malpractice lawsuits

why do fraud, waste, and abuse happen?

- Personal values (or needs) come first

- Opportunities become readily available

- Personal values 'justify' the misconduct

other contributing factors that go into fraud, waste, and abuse =

- Capabilities and function of the fraudster

- Culture and attitudes toward 'the system'

- Opportunities for collusion

- Defensive medicine (waste)

what is the bottom line when it comes to fraud, waste, and abuse?

losses ultimately increase costs for all healthcare stakeholders, continuing to impact the ability to pay and reimbursement

what is the false claims act (FCA) in fraud legislation?

imposes liability on any person who submits a claim to the federal government (eg, Medicare or Medicaid) that he or she knows (or should know) is false

what is the anti-kickback statute (AKS) in fraud legislation?

a criminal law that prohibits anyone from "knowingly and willfully" receiving a form of payment in return for referring a patient to another provider for services or items covered by Medicare or Medicaid

what is the stark law in fraud legislation?

The Physician Self-Referral Law prohibits physician referrals of designated health services (DHS) for Medicare and Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity, unless an exception applies

what is the exclusion statute in fraud legislation?

Department of Health and Human Services is required to exclude health care providers and suppliers who have been convicted of certain crimes from participation in all federal health care programs

6 ways for deterrence, detection, amd mitigation =

- Ethics and compliance policy and procedures and training

- Routine and "surprise" audits

- Systematically review insurance contracts

- Data management and security

- Limit/restrict financial access (p-cards, bank accounts, etc.)

- Have a Compliance Officer: fraud hotline (with option for anonymity); Whistleblower rewards

5 barriers to success =

- Work environment and local culture

- Lack of effective internal controls

- Outdated technology

- Minimal ethics training

- Industry dynamics