Health Care Fraud

Health Insurance Portability and Accountability Act (HIPAA) - Five Federal Crimes Directed at Healthcare fraud... it's illegal to...

1) Defraud health care benefit program; 2) Embezzle/steal funds or assets of health care benefit program; 3) False statements re: healthcare matters; 4) Obstruct/mislead investigations of federal health care offense; 5) Illegal to knowingly execute (or attempt to execute) a scheme intended to defraud a health care benefit program by fraudulent means, obtain money or property owned by healthcare company.

What are the three payment systems in health care

1) Direct system - Patient pays directly from own funds; 2) Single payer - Government healthcare program pays provider on behalf of patient who receives services. Might be copayment. 3) Third party payer - Small number of countries (USA too) do this. Patient is responsible for health bill, doctor renders care, and insurance company pays the doctor or second party provider.

Patient Protection and Affordable Care Act (PPACA)

2010 federal legislation designed for comprehensive health reform, with an intent to expand coverage, control health care costs, and improve the health care delivery system

Overview of Medicare system

65+ or disabled.

The Medicare and Medicaid Anti-Kickback Statutes

Aka Federal Health Care Anti-Kickback Statute. Prohibits people from making payments to induce purchase of health care goods or services that will be paid for by a health care program.

Health Information Technology for Economic and Clinical Health Act (2009)

Amended provisions created by HIPPA. Strengthened criminal/civil enforcement. Made business associates of providers potentially liable. Created criminal liability for obtaining or disclosing of health information maintained by covered entities without authorization.

Define health care benefit program

Any public or private plan or contract affecting commerce, under which any medical benefit, item, or service is provided to an individual.

The Stark Law (Aka Physician Self-Referral)

Attempts to limit ability of the physician to prove from their referral by prohibiting doctors from referring medicaid/Medicare patients to health care facilities where doctor or immediate family members has financial relationship. There are exceptions (like if they're in the same practice group/office).

Money Laundering

Criminalizes financial transactions involving proceeds of illegal activity.

What are civil remedies for Health Insurance Fraud?

False Claims Act and RICo allow for civil remedies. Most effective is u under Civil Monetary Penalties Law - administrative actions can be invoked against provider who defrauds any federally funded program.

Most common type of health care fraud

False statement or misrepresentation critical to determine benefits.

Overview of Medicaid System

Federal and Start funded for low-income families/children. States establish standards and administer their own program.

Criminal False Claim Act

Illegal to present or make a false claim against any agency or department in US.

What does the PPACA do to criminals?

Increased federal sentencing guidelines. Tougher sentences!

What did the PPACA do to premium rebates?

Insurers have to spend a certain amount on medical care and quality improvements. The rest has to go back to the customer.

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

Joint effort between the Dept. of Health and Human Services (HH) and the department of Justice (DOJ) to fight health care fraud.

False Statements

Law prohibits a person from lying on or concealing information from federal officer. Must be about a material fact and capable of influencing agency outcome.

Who manages Medicaid and Medicare systems?

Managed by Centers for Medicare and Medicaid Services - a federal agency within the US Department for Health and Human Services.

State Level Enforcement of Medicaid

Medicaid Fraud Control Unit (MFCU) programs help states counter Medicaid Fraud. Each state must implement its own MFCU. The government subsidizes a lot, but the only way states can keep from establishing an MFCU is to certify that there's no fraud in their state.

Method for calculating compensation - Capitation

One lump sum for each patient doctor treats, regardless of service.

Method for calculating compensation - Salary

Pay provider basic salary as oppose to service based.

Method for calculating compensation - Episode of Care

Provider receives lump sum for all services they provide related to a condition or disease.

Methods for calculating compensation - Fee for Service Reimbursement

Provider receives payment for each service rendered.

Civil False Claim Act

Provides separate civil clause. Allows government to recover penalties and damages for false claims.

Computer fraud

Schemes that use a computer as an instrument by which funds could be illegally transferred can be prosecuted.

Very commonly prosecuted acts under Civil False Claim Act

Use of false/fraudulent records to avoid payment to the government, receipt of false or fraudulent claims paid by government. i..e doctor billing for services rendered by resident as if service was performed by them; billing for uploaded medical services covered; misdiagnosing beneficiaries as having medical condition, etc.

Health Care Fraud

an intentional deception or misrepresentation that an individual or entity makes knowing that the misrepresentation could result in unauthorized benefit to the individual, to the entity, or to some third party

Fraud Abuse Control Program (FACP) (Launched by HIPPA)

operated jointly by the Dept. of Justice and the Office of Inspector General (OIG) to control health-care fraud and abuse and conduct investigations relating to the delivery of health-care services.