Fraud, waste, and abuse

what does fraud, abuse, and waste result in

• Overutilization of services

• Increased costs for payers

• Corruption of medical decision making

• Unfair competition

• Harm to patient

fraud

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

abuse

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

waste

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

major fraud and abuse laws

• False Claims Act

• Federal Anti-Kickback Statute

• Physician Self-Referral Law

• Exclusion Authorities

• Civil Monetary Penalty Law

false claims act

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

• Monetary penalties of between $5,500 and $11,000 per claim, plus 3 times the damages sustained by the government

• License sanctions and exclusion from federal program

knowing

includes actual knowledge, deliberate ignorance, and reckless disregard for the truth or falsity of the information

• Can’t choose to ignore information

how much cn whistleblowers reciver for reporting fraud

up to 30%

ant-kickback statute

• 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

• Payment can include anything of value (eg cash for referrals, free rent, gifts)

• Safe harbors permit nonabusive arrangements

physican self-referral law

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

• Financial relationships include ownership and compensation

who is excluded from the statute

The government may exclude inviolate providers from participation in federal health care programs, meaning:

• The provider may not bill for treating patients

• An employer may not bill for the provider’s services

PT relationships with payors

• coding and billing

• documentation

• enrollment

coding and billing for PTs

• Payers rely on physical therapists to submit proper claims for payment with accurate information

• When the federal government pays for services for Medicare and Medicaid beneficiaries, federal fraud and abuse laws apply

• For private payers, states may have similar laws that apply

PT documentation

• Documentation is a professional responsibility and legal requirement

• Physical therapists must support the claims they submit with complete medical records and documentation

• Payers may review the medical records to verify the claims and quality of care through audits

• Is a record of patient care

• Is a communication vehicle among providers

• Demonstrates compliance with federal, state, payer, and local regulations

• Can demonstrate appropriate utilization

problems Medicare has identified with PT documentation

• Missing or incomplete plan of care

• Missing physician signatures and dates

• Missing total time for procedures and modalities

• Missing certification and recertification of plan of care

enrolling as a medicare and medicacid provider

• Physical therapists in private practice should individually enroll in the federal health care programs to be paid for services to Medicare or Medicaid beneficiaries

• Enrolled physical therapists are responsible for making sure correct claims are submitted and for updating enrollment for any changes

relationships with physicans and other refferal sources

• rental of office space

• medical directors

• gifts to physicians

If a health care business offers something for free or below fair market value, or offers cash in exchange for referrals, question the reason:

• Am I getting paid by a company for very little work? Do they need my expertise?

• Does the amount of money I am offered seem appropriate for services I am going to provide

• Am I being asked to refer patients to that particular company?

rental of office space from physicans

• Do not pay for more space than necessary

• Do not pay greater than fair market value

medical directors

• Should actively oversee clinical care, be involved

• Should be paid fair market value

• Should spend an appropriate amount of time providing services

gifts to physicians

• Caution: Gifts could be considered an inducement to refer patients to your practice (potential violation of anti-kickback laws)

• Stark II law allows nominal gifts

PT relationships with patients

• Gifts to patients

• Waiver of coinsurance

  • Collecting cash from Medicare beneficiaries

Are gifts allowed to MEdicare and MEdicaid benefiiairies

no

gifts thate are allwoed

• Not cash or cash equivalents; and

• Value is no more than a $10 individually/$50 in aggregate annually per patient

coininusrance with paitients

• Providing free services to patients or waiving coinsurance and deductibles is generally prohibited as it may influence a patient to receive your services

• There is an exception for financially needy patients

exceptions to discounts or waivor violations

• Provider does not advertise discounts or waivers of copays

• Provider does not routinely waive copays

• Provider shows extensive efforts to collect money from patient or

• Patient meets federal poverty guidelines or facility-specific poverty/catastrophic guidelines

execptions for discounts

• OIG and HHS issued letters to hospitals 02/04 (applicable to physicians/PTs)

• Discounts to uninsured and underinsured okay

• Must establish a policy and apply it uniformly

• Documentation important

can a medicare patient pay out of pocket

• A physical therapist may not collect out-ofpocket payment from a Medicare beneficiary for a service that Medicare would cover

• There are claims submission requirements under Medicare for covered services

compliance programs

• Compliance programs can prevent fraud, abuse, and waste V

• oluntary compliance program guidance is available from OIG

• 7 core elements for a compliance program

7 core elments of compliance progam

1. Written standards of conduct, policies, and procedures

2. Designation of a compliance officer

3. Effective education and training programs

4. Hotline to receive complaints

5. System to respond to allegations of improper and/or illegal activities

6. Audits to monitor compliance

7. Investigation and remediation of identified systemic problems

what to do if there is a problem with a compliance program

• Contact the compliance officer

• Immediately stop submitting problematic bills

• Seek knowledgeable legal counsel

• Determine whether there are any overpayments that need to be returned

• Disentangle yourself from problematic relationship

• When appropriate, consider reporting information to OIG or CMS