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Fraud and Abuse in Medicare-What You Need To Know

Fraud and Abuse in Medicare-What You Need To Know. Presented to The American Academy of Professional Coders Woodland Hills, California Christopher Gagnon, Fraud Investigator/ September 19, 2013. Agenda. SGS Overview Fraud and Abuse –Definitions and Effects SGS Investigations

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Fraud and Abuse in Medicare-What You Need To Know

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  1. Fraud and Abuse in Medicare-What You Need To Know Presented to The American Academy of Professional Coders Woodland Hills, California Christopher Gagnon, Fraud Investigator/ September 19, 2013

  2. Agenda SGS Overview Fraud and Abuse –Definitions and Effects SGS Investigations Areas of Concern What to Do If You Suspect Fraud Q & A

  3. SafeGuard Services, LLC Overview • SGS has served as the incumbent Program Safeguard Contractor (PSC) for: • Medicare-Medicaid for California since 2001 • Medicare Part B in California since 2002 • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for Jurisdiction D encompassing seventeen states, including California, Nevada, and Hawaii since March 2006 • Zone Program Integrity Contractor (ZPIC) Zone 1 operations, integrating Parts A, B, and DME, Hospice and Home Health claim types for fraud detection and prevention in California, Nevada, American Samoa, Guam, Hawaii, the Northern Mariana Islands, Palau, Marshall Islands, and the Federated States of Micronesia since December 2010

  4. CMS Definitions • Medicare Fraud • When someone intentionally falsifies information or deceives Medicare. • Medicare Abuse • When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren't medically necessary.

  5. Effects Of Medicare Fraud & Abuse • $60 Billion Estimated Annual Loss • Increased Costs of Healthcare – Throughout the Industry • Affects Everyone • Taxpayers • Beneficiaries • Providers / Suppliers • Insurers • Increased Scrutiny of All Claims • Greater Burden for Beneficiaries & Providers • Restrictions of Access to Care for Beneficiaries • Unfair Competitive Advantage Over Legitimate Providers • Damaged Reputation for Healthcare Industry

  6. SGS Investigations What We Investigate • Allegations of Fraud, Waste and Abuse related to Medicare-Enrolled Providers/Suppliers Who We Investigate • Hospitals, Home Health Agencies, Hospice Care (Part A) • Physicians, Clinics, Testing Facilities, Labs (Part B) • DME Suppliers (DME) What We Do Not Investigate • Billing Errors • Disputes Over Quality Of Service Issues

  7. SGS Investigations Where Do our Leads Come From? • External Referrals • Fraud Prevention System (FPS) • Medicare Administrative Contractor • Beneficiaries • Providers • Centers for Medicare & Medicaid Services • Senior Medicare Patrol • OIG Hotline Database • Medi-Cal • Law Enforcement • Internally • Data Team • Investigators

  8. SGS Investigations Schemes And Scams • Beneficiary Sharing • Use of Cappers and other Illegal Marketing • Soliciting, Offering or Receiving a Kickback, Bribe or Rebate • Provider/Beneficiary Identity Theft • Over Utilized Services • Providing Unnecessary or Inappropriate Services • Billing For Services Not Rendered • Up-coding (Provider claim forms which have been altered to obtain a higher payment amount • DME’s-IDTF’S-Clinics-Physician Assistants • Hit and Run • Non-existent Provider Office Locations (i.e., False Fronts, Store Fronts)

  9. Investigative Steps • Review of Claims History • Beneficiary Information • Provider Information • Payment Information • Review of Multiple Data Bases • Review of Internal Reports/Data Analysis • Patients and Hours per day • Proximity to Office • Peer Comparisons • Review of Internet Sites • Such as Medical Board • Obtain Provider Enrollment Applications

  10. Investigative Steps • Prepayment Review May be Initiated • Obtain Sample of Claims Universe • Order and Review Medical Records • Post Payment Review by our Medical Review Team • Perform Beneficiary Validations and/or Interviews • Review Existing Complaints • Perform Provider Interviews • On-sites • Telephone

  11. Outcomes of Investigations Any or All of the Following: • Allegation Not Validated/Closed with No Actions Necessary • Possible Administrative Actions • Calculate Overpayment • Prepayment Review • Deactivation • Revocation • Payment Suspension • Referral To Law Enforcement

  12. Examples

  13. Areas of Concern From a Coders Perspective • Egregious Up-coding • Suites of Codes • Unusual Codes for Specialty • Consistent Use of Qualifying Modifiers • Pressure from Provider to Change the Codes or Diagnoses

  14. What To Do If You Suspect Fraud or Abuse 1-800 Medicare (1-800-633-4227) The OIG Hotline • Phone: 800-409-9926 • The Office of Inspector General, HHS website https://forms.oig.hhs.gov/hotlineoperations • Mail: Office of Inspector General HOTLINEP.O. Box 9778Arlington, Virginia 22219

  15. In Closing QUESTIONS?

  16. ZONE 1 CONTACT INFORMATION • Melisa Mulcahy • Program Director • 916-317-2196 • melisa.mulcahy@hp.com • Beth Romig • Benefit Integrity Manager • (530) 896-7053 • Beth.romig@hp.com • Travis Moore • Acting Manager-Task Order 1 • (213) 553-5237 • travism@hp.com • Mike Devlin • Manager-Task Order 2 • (530) 896-7054 • Mike.devlin@hp.com

  17. Thank you

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