Chapter 11 + quiz
Physician Compliance Programs 7 components
1 Conduct internal monitoring and auditing 2 Implement compliance and practice standards 3 Designate a compliance officer or contact 4 Conduct appropriate training and education 5 Respond appropriately to detected offenses and develop corrective action 6 Develop open lines of communication with employees 7 Enforce disciplinary standards through well-published guidelines
medicare fraud (1/4)
According to the Medicare Learning Network, Medicare fraud and abuse is a serious problem and requires all of our attention. 1/4
Physician Compliance Programs Establish Practice Standards
After the internal audits are completed and if they have identified any risk areas, the next step is to develop a method for dealing with those risk areas through practice standards and procedures. Written standards and procedures are a central component of any compliance program.
This title of the PPACA enables patients to be better informed decision makers by requiring nursing homes to provide better quality care, cracking down on fraud and abuse, and disallowing fraudulent providers from relocating their practice to a different state.
Transparency & Program Integrity
Top 10 Ways Consumers Can Help Fight Medicare Fraud (continued) 4-6
4- The patient may request the assistance of their local Senior Medicare Patrol program in reviewing their Medicare claims statement or MSN. 5- The patient should be aware of or recognize any potential sources of fraud including unrecognized claims on their MDS, suspicious advertisements from companies. 6- Patients should not use another person's Medicare card
Physician Compliance Programs
A guide that is intended to assist individual and small group physician practices in developing a voluntary compliance program that promotes adherence to statutes and regulations applicable to the Federal Healthcare Programs. There are seven components that provides a solid basis upon which a physician can create a voluntary compliance program.
This entity is responsible for supervision and monitoring of the state Health Insurance Marketplaces.
Center for Consumer Information & Insurance Oversight (CCIIO)
An example of Medicare fraud:
Charging for medical tests that were never performed
physician self referral example 2/2
Date: 2011-02-10 Description: CMS settled several violations of the physician self-referral statute disclosed by general acute care hospital located in Massachusetts (the hospital) under the SDRP. Findings: The hospital disclosed under the SDRP that it violated the physician self-referral statute by failing to satisfy the requirements of the personal services arrangements with certain hospital department chiefs and the medical staff for leadership services and failing to satisfy the requirements of the personal services arrangements exception for arrangements with certain physician groups for on-site overnight coverage for patients in the hospital. Settlement: All violations disclosed were settled for $579,000. 2/2
medicare fraud (2/4)
Fraud is an occurrence where someone intentionally falsifies information or deceives Medicare. Abuse is when a healthcare provider or supplier does not follow good medical practices that results in unnecessary costs, improper payment, or services that are not medically necessary. Fraud can range from an individual or single practitioner to a group of individuals or practitioners to an institution or corporate entity. 2/4
medicare fraud (3/4)
Fraud is not only limited to practitioners, it is now becoming involved with organized crime where they are masquerading as Medicare providers and suppliers. Fraud can be committed by a healthcare provider such as a doctor or healthcare practitioner or supplier. If a provider or supplier knowingly alters a claim form to receive a higher payment amount, it is considered fraud. 3/4
Violation of OIG Exclusion by an Excluded Person (continued) 3/3
If a provider employs or enters into a contract with an excluded person, the provider is subject to CMPs if they provide items or services that are payable by the Federal Healthcare Program. A provider could be subject to CMP liability if an excluded person participates in any way in the furnishing of items or services that are payable by a Federal Healthcare Program. 3/3
Exclusion from Participation in Federal Health Programs 1/3
In 1977, in the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Congress first mandated the exclusion of physicians and other practitioners convicted of program-related crimes from participation in Medicare and Medicaid In 1981, there was the enactment of the Civil Monetary Penalties Law (CMPL) 1/3
Health Care Fraud Prevention and Enforcement Action (HEAT) Team
Is a joint initiative between the Department of Health and Human Services and the Department of Justice The mission is to gather resources across government agencies to help prevent waste, fraud, and abuse in the Medicare and Medicaid programs Reduce the skyrocketing healthcare costs and improve the quality of care by ridding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries. The results of the initiatives in 2012 were 91 people, including doctors and nurses and other professionals, being charged with criminal activity that resulted in a total of $432 million in false billing that encompassed $230 million in home health care, $100 million in community mental health care, and $49 million in ambulance transportation.
Physician Self-Referral Law
Known as the Stark Law Found in 42 U.S.C. Section 1395nn Prohibits a physician from making a referral for certain designated healthcare services to an entity in which the physician, or an immediate member of his or her family has an ownership or investment interest, or with which he or she has a compensation arrangement, unless an exception applies
The Affordable Care Act requires health insurance companies to submit data on the proportion of premium revenues spent on clinical services and quality improvement. If this percentages does not meet minimum standards, the insurance company must issue rebates to enrollees. This is referred to as:
Medical Loss Ratio (MLR)
Medicare Fraud and Abuse Laws (continued) Violations of these laws can result in:
Nonpayment of healthcare claims Civil Monetary Penalties (CMPs) Exclusion from the Medicare Program Criminal and civil liability
Physician Compliance Programs Auditing and Monitoring
Ongoing auditing and monitoring is essential to a successful compliance program. The auditing component of a compliance program will help to evaluate if individuals are properly carrying out their responsibilities and claims are submitted appropriately.
Physician Self-Referral 1/2
Section 1877 of the Social Security Act (42 U.S.C. 1395nn) Known as the physician self-referral law Commonly known as or referred to as the "Stark Law" 1. Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies. 2. Prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third party payer) for those referred services. 3. Establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse. 1/2
False Claims Act (FCA)
Sections 3729-3733 protects the government from being overcharged or sold substandard goods or services. Will impose civil liability on any person who knowingly submits, or causes to a claim to be submitted that is a false or fraudulent claim to the federal government for payment The civil penalties for violating the FCA may include fines up to three times the amount of damages sustained by the government as a result of these false claims being submitted. Can be criminal penalties for submitting the false claims that may include fines, imprisonment, or both.
Top 10 Ways Consumers Can Help Fight Medicare Fraud
The consumer is the first line of defense when it comes to fighting Medicare fraud. This is due to the patient, or consumer, being between the provider providing a service and the provider actually submitting a claim for the services rendered. This makes the patient the first person to identify if anything fraudulent has taken place on their account
CMS Fraud Prevention Initiative
The results of the efforts of CMS have been positive. In 2012, the federal government recovered a record $4.2 billion dollars from people who attempted to defraud seniors and taxpayers. The success of a program like this one is realized in dollars in that for every $1 dollar spent resulted in $3 dollars saved in the first year of this program. CMS has also started a campaign called "Help Prevent Fraud," which educates people on how they can protect themselves against fraud.
Frequency of Screening and Which Individuals to Screen
To avoid any potential liability, providers should check the LEIE prior to contracting or employing a person and then periodically check. The OIG recommends that to best determine which persons should be screened against the LEIE Online Searchable Database, the provider should review each job category or contractual relationship to determine whether or not the item or service being provided is directly or indirectly, in whole or in part, payable by a Federal Healthcare Program System for Award Management (SAM) is another searchable database that is available and includes the OIG exclusions along with debarment actions taken by federal agencies. Other databases available are: The National Practitioner Data Bank (NPDB) The Healthcare Integrity and Protection Databank (HIPDB)
medicare abuse
When a supplier or practitioner either directly or indirectly has practices that result in unnecessary costs to the Medicare Program Includes any practice that is not consistent with the goals of providing patients with quality services that are medically necessary or meet professionally recognized standards and are fairly priced. Examples may include misusing codes on a claim, charging excessively for products or services, and billing for services that were not medically necessary.
Quality of care concerns are considered fraud and these concerns can be addressed by a Quality Improvement Organization.
false
One of the most important physician compliance issues is the appropriate documentation of diagnosis and treatment.
true
Exclusion from Participation in Federal Health Programs (continued) 3/3
An excluded provider may refer a patient to a non-excluded provider if the excluded provider does not furnish, order, or prescribe any services for the referred patient The prohibition on the Federal Healthcare Program payment for items or services furnished by an excluded individual includes items and services that are provided beyond direct patient care. Excluded persons are not permitted to furnish administrative and management services that are payable by Federal Healthcare Programs 3/3
Criminal Health Care Fraud Statute
Found in 18 U.S.C. Section 1347 and prohibits knowingly and willfully: Executing or attempting to execute and 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 that is in the connection with the delivery of or payment for healthcare benefits, items, or services
Anti-Kickback Statute
Found in 42 U.S.C. Section 1320a-7b(b) and makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal healthcare program. Violated when remuneration is paid, received, offered, or solicited purposefully to induce or reward referrals of items or services payable by a federal healthcare program.
CMS Fraud Prevention Initiative Pay and Chase
Centers for Medicare and Medicaid Services (CMS) has implemented some powerful tools that shift the focus from a "pay and chase" approach to a prospective approach that looks to prevent fraud, not only in CMS, but collaboratively with state and law enforcement partners that work on detecting and preventing fraud.
Top 10 Ways Consumers Can Help Fight Medicare Fraud (continued) 1-3
1- When the patient has a doctor's appointment or receives healthcare services, they should record the date(s) on a calendar. 2- They need to review their Medicare claims, Medicare Summary Notices (MSN), and compare them to the services listed on their calendar and the receipts that they have on file. 3- The patient can review their Original Medicare claims, once they have been processed.
Top 10 Ways Consumers Can Help Fight Medicare Fraud (continued) 7-10
7- Patients should protect their Medicare identification number, and only give it out to their doctor or other Medicare providers. 8- Patients need to report suspected instances of fraud by calling 1-800-MEDICARE. 9- Patients should consider becoming a member of the Senior Medicare Patrol (SMP). 10- Patients can learn more about Medicare fraud and ways to protect themselves against fraud and abuse by visiting www.stopmedicarefraud.gov.
Violation of OIG Exclusion by an Excluded Person (continued) 2/3
A person that is excluded by the OIG may own a provider that participates in the Federal Healthcare Program, but there are several risks to this type of ownership. First, the OIG may exclude the provider if circumstances regarding the ownership are present. Second, an excluded individual may be subject to CMPL liability if he or she has an ownership or controlling interest in a provider that is participating in Medicare or a state healthcare program. 2/3
Violation of OIG Exclusion by an Excluded Person 1/3
If an excluded person violates the exclusion that was imposed upon him or her, and furnishes items or services to a Federal Healthcare Program beneficiary and submits a claim for payment of these services, the excluded person may be subject to CMP of $10,000 for each claimed item or service furnished during the period that the person was excluded. The excluded person may also be subject to an assessment of up to three times the amount claimed for each item or service. 1/3
Medicare Fraud and Abuse Laws
In an effort to eliminate erroneous healthcare spending for Medicare and Medicaid programs, Congress passed several acts that target the fraud and abuse that is present in the Medicare and Medicaid systems. There are several laws that govern Medicare Fraud -The False Claims Act -Anti-kickback Statute -Physician Self-Referral Law (Stark Law) -Social Security Act -The U.S. Criminal Code
medicare fraud (4/4)
Punishment for this crime against the federal government may involve imprisonment, significant fines, or both. Criminal penalties for healthcare fraud reflects the serious harms associated with the healthcare fraud and the need for aggressive and appropriate prevention. CMS estimates that the federal government distributed about $65 billion in improper payments, or payments that should not have been made or were for the incorrect amount, through Medicare and Medicaid combined in fiscal year 2011. 4/4
An easy-to-understand summary provided to consumers about a health plan's benefits and coverage.
Summary of Benefits and Coverage (SBC)
National Benefit Integrity and Medicare Drug Integrity Contractor (NBI MEDIC)
Supports CMS Center for Program Integrity, monitors fraud and abuse in Medicare Part C and Part D programs in all 50 states, the District of Columbia, and U.S. Some examples of cases handled are: -When someone pretends to represent Medicare or SSA and asks for a beneficiary's Medicare number -They also investigate if someone is asking a beneficiary to sell their Medicare prescription drug card
The Fraud Prevention System is:
System using predictive analytics to recognize claims that are high risk for potential fraud
Self-Referral Disclosure Protocol
The CMS Self-Referral Disclosure Protocol (SRDP) enables providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute.
Determining if an Individual or Entity is Excluded
The Exclusions website where the LEIE can be found is at https://oig.hhs.gov/exclusions/ The LEIE is a searchable online database and has the availability of downloadable data files. The LEIE Downloadable Data File enables users to download the entire LEIE. The OIG posts supplemental exclusion and reinstatement files on a monthly basis to their website
Physician Compliance Programs specific risk areas
The OIG recognizes that many physician practices may not have in place standards and procedures to prevent erroneous or fraudulent conduct in their practices. The first risk area is coding and billing, which determines if the practice is billing for services not rendered The second area the OIG has identified for the practice is focused on the charges and the services provided by the practice are reasonable and necessary. Timely and accurate and complete documentation is important to clinical patient care
Exclusion from Participation in Federal Health Programs (continued) 2/3
The enactment of the Health Insurance Portability and Accountability Act (HIPAA) and the Balanced Budget Act (BBA) of 1997 further expanded the OIG's sanction authorities. The Health Care Education Reconciliation Act of 2010 (ACA) When a provider is excluded from all Federal Healthcare Programs, there cannot be any payment made for any items or services 2/3
This type of payment program awards Medicare bonus payments to hospitals that reach efficiency and quality benchmarks, in addition to how well they enhance patients' experiences of care during hospital stays. Hospitals are also required to publicly report their program measures.
Value-Based Purchasing (VBP)
The Center for Program Integrity (CPI)
Was created in 2010 and brought together the Medicare and Medicaid program integrity groups under one management structure to strengthen and better coordinate existing activities and to detect fraud, waste, and abuse. Created a more rigorous screening process for providers and suppliers enrolling in Medicare, Medicaid, and CHIP. Required a cross-termination among federal and state health programs where if a provider lost privileges under Medicare that the provider would also lose privileges under Medicaid and CHIP.
Zone Program Integrity Contractors (ZPICs)
Were created to perform program integrity functions in zones for Medicare Part A and Part B, Durable Medical Equipment (DME), Prosthetics, Orthotics, and Supplies, Home Health and Hospice, and Medicare-Medicaid data matching Responsibilities -Investigate leads generated by the new Fraud Prevention System (FPS) -Perform data analysis to identify cases of suspected fraud -Make recommendations to CMS for appropriate administrative actions to protect the Medicare Trust Fund dollars
When a provider is excluded from all Federal Healthcare Programs, there cannot be
any payment made for any items or services furnished by an excluded person services provided at the direction of or on the prescription of an excluded person payment for administrative services, such as IT or staff training, provided by the excluded person