Fraud, Abuse, Waste

How much is lost due to fraud abuse and waste per year?

$765 billion

Results of fraud, abuse, and waste

Over-utilization of services, increased costs for payers, corruption of medical decision making, unfair competition, harm to patient

ROI for the Heath Care Fraud and Abuse control program

$8.10 returned for every $1.00 expended→ $4.3 billion recovered in 2013

intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled

fraud

examples of fraud

Knowingly billing for services not furnished, Knowingly altering claims forms to receive more payment, Falsifying documentation

payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment

abuse

examples of abuse

Billing services that are not medically necessary, Unbundling services and billing, Billing services that do not meet professionally recognized standards

incurring unnecessary costs as a result of deficient management practices, systems, or controls

waste

examples of waste

Duplication of services already provided elsewhere, Spending on services that lack evidence of producing better outcomes compared with less expensive alternatives

Prohibits the knowing submission of false claims or the use of a false record or statement for payment to Medicare or Medicaid

False Claims Act

What does “ knowing” include under the false claims act

actual knowledge, deliberate ignorance, and reckless disregard for the truth or falsity of the information (can’t choose to ignore info)

incentives for whistleblowers under false claims act

Can receive up to 30% of recovery (may include ex-business partners, staff, competitors, patients)

Prohibits anyone from “knowingly and willfully” offering or receiving a form of payment in return for referring a patient to another provider for services or items covered by Medicare and Medicaid

Anti-Kickback Statute

Prohibits physician referrals for certain health care services (eg, physical therapy) when there is a financial relationship with an entity unless an exception applies

Physician Self-Referral/Stark Law

PT relationships w/ payers

coding/billing, documentation, enrollment

when are gifts to patients allowed?

when they are not cash or cash equivalents and the value is no mole than $ individually and $50 in aggregate annually per pt

Exceptions to discounts or waiver violations

provider does not routinely waive copays, provider does not advertise discounts or waivers of copays, provider shows extensive efforts to collect money from pt or pt meets federal poverty guidelines or facility specific poverty/catastrophic guidelines, OIG and HS issued letters to hospitals, uninsured/underinsured, established policy applied uniformly, doccumentation

Can a PT collect out of pocket payment from a medicare beneficiary for a service that medicare would cover?

no

7 core elements of a compliance program

written standards of conduct/policies/procedures, designation of compliance officer, effective education and training programs, hotline to receive complaints, system to respond to allegations of improper/illegal action, audits to monitor compliance, investigation and remediation of identified systemic problems