HITT 1106 Chapter 18
provider self defense protocol
mechanism for providers to voluntarily disclose self discovered evidence of potential fraud to the oig
two types of healthcare claims the gov deems false
1. furnishing inaccurate or misleading information to the government to obtain payment or approval of a claim, such as upcoding or submitting claims for services not rendered 2. omission of information from a claim or implicitly certifying compliance with rules, without actually complying with the rules
Recovery Audit Contractor (RAC)
A governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments
Knowing standard
A method of determining Federal Claims Act liability, requiring that the provider must have knowingly submitted the false claim
qui tam relator
A term used to apply to an employee who provides information to the government about a company's wrongdoing and under the Federal False Claims Act, this whistleblower may receive a portion of the recovered funds.
compliance officer
Designated individual who monitors the compliance process at a healthcare facility
complex review
In a revenue audit contractor (RAC) review, this type of review results in an overpayment or underpayment determination based on a review of the health record associated with the claim in question
Deficit Reduction Act of 2005
Made compliance programs mandatory. any entity making at least 5 mil dollars in medicaid payments is required to establish written policies for all employees and for any contractor or agent
Comprehensive Error Rate Testing (CERT) program
Measures improper payments for the Medicare fee for services payment systems as mandated by the Improper Payments Elimination and Recovery Improvement Act of 2012
What has the Government Accountability Office designated a high risk program?
Medicare
automated review
Payer's computer system that applies edits that reflect their payment policies. Check's for correct coding and coding policies. - patient eligibility for services - Time limits for filing claims - preauthorization and referral validity - duplicate dates of sercie - noncovered services - valid code linkages - bundled codes - medical review - utilization review - concurrent care
healthcare abuse
Provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices, which directly or indirectly may result in unnecessary costs to the program, improper payment, services that fail to meet professionally recognized standards of care or are medically unnecessary, services that directly or indirectly result in adverse patient outcomes or delays in appropriate diagnosis or treatment.
OIG work plan
The OIG's annual list of planned projects under the Medicare Fraud and Abuse Initiative
fraud
a false representation of fact, a failure to disclose a fact that is material to a healthcare transaction, and damage to another party that reasonably relies on the misrepresentation or failure to disclose
Health Care Fraud Prevention and Enforcement Action Team (HEAT)
a joint HHS and DOJ initiative to combat medicare and medicaid fraud. they use real time data analysis to investigate healthcare fraud cases, rather than a prolonged subpoena and account analyses. results in shorter period of time between fraud identification, arrest and prosecution
open lines of communication
a mechanism for staff members to report compliance violations or suspected violations. should be anonymous so employees feel comfortable reporting
Healthcare Fraud Prevention Partnership (HFPP)
a voluntary public-private partnership between the federal government, state officials, law enforcement, private health insurance plans and associations and healthcare anti fraud associations. the goal is to foster a proactive approach to detect and prevent healthcare fraud through data and info sharing
corporate compliance
adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct
corporate compliance program
an internal set of policies, processes and procedures that an organization implements to help it act ethically and lawfully. helps est. a culture that promotes prevention, detection and resolution in instances of conduct that do not conform to state or federal law
upcoding
billing for a service at a higher level than was actually provided; falsifying the patients dx so that it supports the fraudulent service or procedure
unbundling
billing individual components for a complete procedure or service seperately
supplemental medical review contractor
charged with performing or providing support for a variety of tasks aimed at lowering improper payment rates and increasing efficiencies of the medical review functions of the medicare and medicaid programs
HIPAA
created a statutory provision that prohibits knowingly and willfully executing a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program, in connection w the delivery of or payment for healthcare benefits, items, or services
remuneration
defined broadly to include the transfer of any value, directly or indirectly, overtly or covertly, in cash or in kind
improper payment
defined by the fed government as any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements
Civil Monetary Penalties Law (CMPL)
enacted by congress, it authorized the secretary and inspector general of hhs to impose cmps, assessments, and program exclusions on individuals and entities whose wrongdoing caused injury to hhs programs or their beneficiaries
Federal Anti-Kickback Statute
enacted in 1972 to protect patients and federal healthcare programs (such as Medicare and Medicaid) from fraud and abuse by reducing the influence of money on healthcare decisions. (LaTour 858)
Corporate Integrity Agreement (CIA)
enforcement tool used by the hhs oig to improve the quality of healthcare and to promote compliance with healthcare regulations
education and training
essential elements of a compliance plan and should be a part of employee's training and an ongoing continuing education activity for staff
Patient Protection and Affordable Care Act
expanded the federal governments ability to combat fraud and abuse
The Fraud Enforcement and Recovery Act of 2009
expanded the potential for liability under the FCA and expanded the gov's investigative powers. eliminated the requirement that a person must present a false claim to a us gov officer or employee, etc. in order to be liable under FCA
corporate code of conduct
express the organization's commitment to ethical behavior. this should be included in a compliance plan
Medicare Shared Savings Program (MSSP)
focuses on coordinating care between and among providers, including those that are potential referral sources for one another. this potentially implicates fraud and abuse laws that address financial arrangements between sources of federal healthcare program referrals and those seeking such referrals
referral
for MCR B services: the request by a physician for the item or service for all other MCR and MCD services: the request or establishment of a plan of care by a physician which includes the provision of the designated health service
Health Care Fraud and Abuse Control Program
government program to uncover misuse of funds in federal health care programs run by the Office of the Inspector General
accountable care organizations
groups of providers and suppliers meeting certain criteria that work together to manage and coordinate care for medicare fee-for-service beneficaries
offense detection and correction action initiatives
important that the compliance officers or other management initiate prompt steps to determine what has occurred and what steps need to be taken to correct the problem
whistleblowers
insiders who report illegal or unethical behavior
advisory options
interpretations that apply the code of professional conduct to specific fact situations
national benefit integrity (NBI) medicare drug integrity contractor (MEDIC)
investigates fraud, waste, and abuse in the medicare parts c and d programs
Sherman Antitrust Act (1890)
makes it illegal to restrain trade through contracts or conspiracies and they prohibit price fixing and mergers that lessen competition
corporate compliance in the context of healthcare
meeting the statutory and regulatory requirements set out for particular activities in the provision of healthcare
are corporate compliance programs mandatory?
no, but if a provider wants to be enrolled in federal healthcare programs it is
waste
overutilization or inappropriate utilization of services and misuse of resources. not considered a criminal or intentional act
Medicare Administrative Contractor (MAC)
private health plans that have been awarded a geographic jurisdiction to process mcr a and b medical claims or durable medical equipment claims for medicare fee-for-service beneficiaries
Zone Program Integrity Contractor (ZPIC)
program implemented in 2009 by CMS to review billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community. ZPICs are assigned to the Medicare administrative contractor (MAC) jurisdictions, replacing the Program Safeguard Contracts (PSCs).
Federal Physician Self-Referral Statute (Stark Law)
prohibits physicians from referring medicare or medicaid patients for certain designated health services to an entity which they have a compensation arrangement, unless an exception applies
safe harbor
protect certain payment and business practices that could potentially implicate the AKS from criminal and civil prosecution. must meet certain requirements
department of health and human services office of inspector general
responsible for protecting the integrity of hhs programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste and abuse; identifying ways to improve program economy and efficiency; and holding accountable those who do not meet requirements or who violate federal healthcare laws
auditing and monitoring
should be focused and ongoing while recognizing that its not possible to monitor everything that is done all the time. high priority targets include identified high risk areas, problem prone activities and high dollar and high volume services
enforcing disciplinary standards through well published guidelines
should have disciplinary policies to lay out consequences of violating the organization's standards of conduct, policies and procedures
policies and procedures
the compliance plan must include this that define the compliance and claims submission in the organization, including policies for identifying and reporting overpayments
False Claims Act of 1986
the governments main tool for fighting fraud. anyone who knowingly submits or causes submissions of false claims is liable for civil and/or criminal penalties. Any bystanders who act in deliberate ignorance to the fraud are also punished
Physician self-referral
the practice of physician referring a patient to a medical facility in which s/he has a financial interest, be it ownership, investment, or a structure compensation agreement. significant fraud risk area
what is needed for a compliance plan to be effective?
there should be oversight. the OIG calls for someone to be responsible for the overall administration of the compliance activities in an organization
Medicaid Integrity Contractors
will identify overpayments of Medicaid, but unlike their counterparts, they are not involved in the collections of any such overpayments
