Health Care Fraud - Don’t Do It!

July 31st, 2017 - Chris Woolstenhulme, CPC, CMRS
Categories:   Insurance   Compliance  
1 Vote - Sign in to vote or comment.

If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely seriously. I don't need to tell you this. 

I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate claim? In short, fraud is an intentional deception or misrepresentation.   

Let’s not panic; there is a distinction between intentional fraud and an error. In regards to the 46 year old Denver woman, it was proved to be intentional. This was not an accidental duplicate claim.

The OIG posted this article on July 27th, 2017. 

"Denver Woman Sentenced To 46 Months’ Imprisonment for Health Care Fraud"

The US attorney’s office reported, “According to United States Attorney Bruce D. Brandler, as a result of prior convictions relating to Medicaid fraud, Sensenig was excluded from providing healthcare to Medicaid beneficiaries. In order to obtain a position as a behavioral health consultant, Sensenig made false representations, including a forged background check, in order to hide her ineligible status. As a result, Medicaid paid approximately $84,500 for her services."

USA Today reported on July 13th, 2017:

"Jeff Sessions: 400 medical professionals charged in largest health care fraud takedown"

“Sessions said the suspects accounted for more than $1.3 billion in fraudulent transactions across more than 20 states, and at least 120 people were charged for their alleged roles in overprescribing and distributing opioids, making it also the largest-ever opioid-related fraud takedown.

Of the 412 charged in the year-long operation, 56 were physicians.”

Of course, the OIG has a most wanted fugitive list. If you ever decide you want your name on that list and make a contentious decision that is your goal in life, and you no longer need your license you worked so hard for, you can get on this list. Hint: you never want to be on that list, but just in case you have any questions about how to get on it, here are just a few areas of conduct that will certainly place your name on the OIG’s most wanted list.

  • Bill Medicare for durable medical equipment (DME) and supplies that either were not provided or were medically unnecessary
  • Conspiracy to defraud the United States
  • Commit health care fraud
  • Pay kickbacks
  • Money laundering 
  • Conspiracy to commit money laundering
  • Medical treatments that were never provided or were medically unnecessary
  • Aggravated identity theft
  • False claims
  • False statements related to health care matters
  • Falsification of records
  • False Medicare claims for durable medical equipment (DME) that was medically unnecessary or was not provided to beneficiaries

Some of the less obvious but common areas of fraud are just as serious, such as: 

  • Waiving patient co-payments and deductibles
  • Prescribing drugs unnecessarily
  • Inaccurate reporting of patient diagnoses and procedures

This list could go on-and-on. The other side to this is that it's not only payers and the government that pays for dishonest providers; the affect is far-reaching. Starting with the elderly, Medicare beneficiaries are commonly scammed using benefits that count toward a lifetime or other limited benefit. On an even more personal note, it is estimated that American taxpayers will pay between $50-90 Billion annually for Medicare fraud alone.

Most providers follow good medical practices, are outstanding providers, and take their oath seriously. The National Health Care Anti-Fraud Association (NHCAA) states the majority of healthcare fraud is committed by a very small minority of dishonest healthcare providers.”

We can all do our part by keeping an eye out for perpetrators of healthcare fraud. Lowering health care fraud and abuse should potentially begin to lower healthcare costs. This certainly affects all of us personally.

To report Medicare fraud, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you’re a TTY user, call 1-877-486-2048.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Where is the CCI Edit with Modifier 25 on E/M?
May 20th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.  The use of Modifier 25 is one example ...
Packaging and Units for Billing Drugs
May 18th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number. Take a look at the following J1071 - Injection, testosterone cypionate, 1mg For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL (100 mg/mL = 1 mL and there are ...
Getting Your Practice Back on Track
May 12th, 2020 - Wyn Staheli, Director of Research
As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.
ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting
May 5th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI).  The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms.  ICD-10-CM Official Coding Guidelines - ...
Additional Telehealth Changes Announced by CMS
May 4th, 2020 - Wyn Staheli, Director of Research
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
Effective Risk Adjustment Requires Accurate Calculations
April 27th, 2020 - Wyn Staheli, Director of Research
Risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology based on the diagnoses of the individuals in that population. As payers move to value based models, they heavily rely on risk adjustment to ensure proper funding.
COVID-19 Clinical Trial Participation Helps Providers Earn MIPS Credit
April 22nd, 2020 - Wyn Staheli, Director of Research
All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association