Healthcare Fraud, waste and abuse

Every year the Federal Government reports billions of dollars of Medicare program losses and costs due to fraud, waste, and abuse (FWA). The FBI estimates that healthcare fraud accounts for

3% to 10% of the cost of healthcare in the U.S., which totals up to $75 to $250 billion per year.

Penalties

False Claims Act payments include civil fines and penalties. Federal penalties can amount to three times the program's loss plus $11,000 per claim filed. There are possible criminal penalties and fines, including imprisonment. Additionally, health providers can be precluded from working with Medicare and Medicaid in the future. Non-compliance can result in civil and criminal penalties, False Claims Act liability, and potential exclusion from federal healthcare programs. Criminal violations may result in fines, jail terms, and exclusion from participation in Federal health care programs.

Here are some examples:

Fraud: Billing for services that are not provided and falsifying medical records to obtain payment. Waste: Conducting excessive office visits and ordering excessive diagnostic tests. Abuse: Submitting claims for services or procedures that pay more than another service or procedure - regardless of CPT coding or local coverage determination guidelines for medical necessity.

Fraud

Knowing, intentional deception, or misrepresentation to obtain the money or property of a federally funded or other healthcare benefit program. 'Knowing' means actual knowledge, deliberate ignorance, or reckless disregard of the truth or falsity of the information.

Waste

Overutilization of services or other practices, not caused by criminally negligent actions, that directly or indirectly result in the misuse of resources and unnecessary costs to a healthcare benefit program.

Anti Kickback statute

The Anti-Kickback Statute [42 U.S.C. Section 132a-7b(b)] prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs, (e.g., drugs, supplies or health care services for Medicare or Medicaid patients). Remuneration includes anything of value, not just cash, such as free office rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.

True or false? Fraud can be defined as an intentional deception to obtain money from the Medicare program.

True

Abuse

Without knowing and/or intentional misrepresentation of facts, obtaining money or services to which there is no legal entitlement that directly or indirectly results in a financial loss to the healthcare benefit program.

Qui Tam Whistleblower Provision

allows any person with actual knowledge of false claims activity (referred to as a whistleblower), to report the activity if they're the first to provide original information. The whistleblower may be rewarded a percentage of what the government recovers, depending on various factors. A whistleblower does not have to be an employee or an otherwise insider to report false claims activity. That said, employee whistleblowers are more common and are protected from employer retaliation. If retaliation occurs, they may receive employment reinstatement, back pay, and any compensation arising from retaliatory conduct.

False Claims Act (FCA)

no specific intent to defraud is required. This law prohibits knowingly presenting a false or fraudulent claim to the federal government for payment. "Knowingly" includes not only actual knowledge but also: Deliberate ignorance of the truth Reckless disregard of the truth