Case Study Medicare Claims

When providers or patients submit false or misleading information intentionally to a health plan, this is fraud. Some examples of healthcare fraud and abuse include filing claims for services or medications not actually performed or obtained, billing for services for non-covered items using codes for billable services or items, altering medical records, waiving co-pays and deductibles, up coding and unbundling, using someone’s insurance card, billing Medicare patients at a higher fee than non-Medicare patients, and accepting kickbacks for referring patients, to name just a few. Fraud can be committed by hospitals, medical providers, laboratories, pharmacists, billing services, medical equipment suppliers, and even patients. Patients can protect themselves from healthcare fraud and abuse by knowing their healthcare benefits, reviewing the explanation of benefits, asking the doctor to explain the service that was given, report discrepancies, protect insurance cards and member identification numbers, beware of free services, report copayment and deductibles being waived, and never sign blank insurance forms.

Medicare fraud is illegal and remedies are sought at both a civil and criminal level. If a provider, practice, or institution is found guilty of Medicare fraud, the consequences may include a loss of license, monetary penalties, and the inability to participate in Federal healthcare programs. The Office of Inspector General (OIG), which is a part of the U.S. Department of Health & Human Services, has the ability to exclude individuals who participate in Medicare fraud. The guilty party will be listed on a searchable database on the OIG website. The list is officially referred to as the List of

When health care providers file a medical claim on behalf of the Medicare patient, it is being filed with the Federal Government, which certifies that the provider earned the payment requested and that the provider also complied with billing requirements. Improper claims are categorized as erroneous and fraudulent claims. Erroneous claims can be classified as applications for reimbursements where innocent and common coding and billing errors have been made. Id. Whereas, fraudulent claims are classified as applications for reimbursements with reckless and international conduct to collect payments for services not provided. Id.

Most health care providers deliver quality medical care to their patients. However, there are some providers that commit health care fraud and abuse. Health care fraud costs an estimated $68 billion to $226 billion annually (Health Care Fraud and Abuse, 2016). It is a crime under federal and state laws and violations can result in loss of health care coverage, fines, and even jail time.

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

The DOJ and HHS created the Stop Medicare Fraud website, which provides information about how to recognize and protect against Medicare and Medicaid misrepresentation and how to report it. In conclusion, the government has moved away from the inefficient and costly fee-for-service payment type and moved toward the value-based reimbursements for health services to help increase patient care and quality outcomes. I believe the FCA and AKS regulatory laws are able of guarding against overutilization, raised costs, and poor quality of care and I look forward to this being debated in the

Healthcare fraud and abuse are different terms that describe different types of deceitful acts done by healthcare professionals or by solo individuals. Fraudulent medical billing is defined as knowingly submitting false statements or making misrepresentations of facts or false documentation to obtain a health care payment. These payments for which no entitlement would otherwise exist, knowingly soliciting, paying, and/or accepting compensation to encourage or reward referrals for items or services reimbursed by federal health care programs and making prohibited referrals for certain designated health services. Fraud healthcare schemes include

fraud risk exclusion from participation in Federal health care programs and the loss of their

Common fraudulent practices include billing for services never received, upcoding or unbundling of services, and mislabeling. Billing dishonest services occurs anytime a healthcare provider charges Medicare for a service the patient never received or billing for a more expensive service than performed. Upcoding and unbundling, two examples of billing for a more expensive service demonstrate this fraudulent practice. Simply put, upcoding occurs by billing more expensive codes than the services performed, while unbundling refers to a “bundled” service broken down or unbundled, allowing procedures billed separately to obtain a higher reimbursement than customary. Mislabeling, the practice of substituting non-covered services or products with services or products covered under Medicare guidelines also constitutes fraud. For example, a home healthcare company commits fraud by mislabeling house cleaning services, not covered by Medicare, as a nurse visit in order to receive payment. A pharmacy filling a patient’s prescription with generic drugs and charging for name brand drugs also represents mislabeling.

You’re sitting at home one afternoon, three weeks prior to the start of Open Enrollment, when you get a call from a friendly Center for Medicare Services (CMS) employee. The caller tells you that Medicare is issuing “new cards,” and that you need to provide your Medicare number, birth date and social security number in order to get yours. The catch? The caller doesn’t work for CMS, and he’s actually trying to steal your identity. Elder abuse is one of the most common crimes of the 21st century. In fact, studies have shown that 2 in 10 older adults have been financially exploited. Read on for 5 tips on avoiding common types of Medicare scams.

Public healthcare applications inclusive of Medicare and Medicaid are particularly conducive to fraudulent activities, as they're frequently run on a price-for-carrier shape.[20] Physicians use several fraudulent techniques to reap this give up. These can consist of “up-coding” or “upgrading,” which involve billing for more high-priced treatments than the ones surely provided; presenting, and in the end billing for, remedies that aren't medically essential; scheduling greater visits for sufferers; referring patients to different physicians when no in addition treatment is really important; "phantom billing," or billing for services now not rendered; and “ganging,” or billing for services to own family members or other people who are accompanying the affected person however who did now not in my view receive any offerings.[20]

Two experienced nurses had been working at the Winkler county hospital for more than 20 years. In 2009, Ann Mitchell and Vicki Galle became whistleblower in the small town of west Texas. The nurses field an anonymous report to Texas Medical Board regarding to retaliation in the hospital. In the letter, the nurse stated the unsafe practices of Dr. Rolando Arafiles. The nurses were concern about the improper treatment to patient provided by Dr. Arafiles. Since. Dr. Arafiles tried to misuse his connections in order to save himself. Upon receiving the notice from the Texas Medical Board, Dr. Arafiles contacted his good friend and patient-Winkler county sheriff. Dr. Arafiles filed a complaint of harassment by the nurses to the sheriff. The sheriff started investigating the complaint and obtained the copy of the TMB report that clearly identifies that Mitchell and Galle had filed a complaint. Then, the sheriff obtained a search of warrant and seized each nurse’s work computer and found the copy of TMB letter. The nurses were charged with the third degree felony for misuse of official information to cause damage to the physician. However, the TMB disputed with District and County Attorney over the charges asserting that there was no misuse of official information in the state-governing agency. The complaint process allows anyone to report a physician for any unsafe, improper or poor practice including nurses. Since TMB is a government agency there was no violation of Health

They review claims before Medicare pays the physician, and an analysis of claims after repayment. They identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services. Every practice should be prepared to be audited at some point. The auditor basically goes around to see if any fraud is being committed. There are different kinds of audits such as Recovery Audit Contractor, Certified Error Rate Testing, and Probe Audits. Some things you can do to prepare your staff is avoid coding mistakes, accurately document patient charts, perform random mock audits, prepare implement policies and procedures, and review audited claims. I should also educate my staff the importance

As enforcement activities increase by the Department of Justice, though the above report of fraud and abuse was intentionally carried out over a seven-year period, it becomes clearer every day that even an unintentional billing mistake can lead to charges of fraudulent billing with severe penalties. In the end, the risks of not having an update to date and strong compliance program can potentially result in the damage financially to the specialty physicians practice and reputation can be substantial. It also requires

As the healthcare industry begins to expand its horizons, by featuring more staff and patients, the types of frauds that are committed also rise in number and complexity. One of the many consequences that derives from fraud within the healthcare system includes an increase in the cost of healthcare itself. In order to limit and analyze fraud that encompasses the entirety of the healthcare industry, it is necessary to assess the different types of frauds and in doing so also understand the method of reimbursement involving the professionals and members of the health care industry. Since a majority of these reimbursements are paid by insurances or through government programs, a program known as coding was created in order to organize and properly pay off these reimbursements(Marilyn Price, Donna Norris, 2009). One of the many