Fraud and Abuse

1. Fraud and Abuse FY 2012, “Federal prosecutors had 2,032 health care fraud criminal investigations pending, involving 3,410 potential defendants, and filed criminal charges in 452 cases involving 892 defendants” (NHCAA, Jan., 2013).

2. “The National Health Care Fraud and Abuse Control Program (HCFAC) was established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Program is carried out jointly at the direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS)” (McWay, 2010). Prevention of Fraud and Abuse is a joint effort.

3. In the health-care context, fraud and abuse means the efforts of a health care provider or organization to misrepresent facts to a government entity or third-party payer so that the misrepresented facts appear legal and customary in the industry and result in some form of benefit, monetary or otherwise, to the health care provider or organizations. Know the definition of Fraud and Abuse.

4. The most common fraud and abuse issues are related to the false claims and billing practices. Such examples would be: • Billing for services not rendered. • Submitting bills for physician’s examination, x-rays, and lab services, which were never delivered to the patient. Most Common Issues

5. Upcoding is the submission of a bill for a higher level of reimbursement than actually rendered in order to receive a higher reimbursement rate. • Unbundling would involve the submission of separate bills for each component of a procedure instead of using the proper procedural code for the entire procedure, resulting in a higher reimbursement rate. Forms of Fraud and Abuse

6. Physician self-referral • The exchange of compensation for patient referrals • Services not medically necessary • Double-billing • Making false statements on a health plan application or adding someone who is not eligible for coverage to a health plan. Other forms of Fraud and Abuse.

7. False Claims Act • Qui tam actions • Anti-kickback statutes • Physician self-referral prohibitions (Stark Laws) • Mail and wire fraud statutes • Health Insurance Portability and Accountability Act (HIPAA) • Deficit Reduction Act of 2005 Major Laws Addressing Fraud and Abuse.

8. The Linchpin for the prosecution of health-care fraud and abuse is the False Claims Act(FCA). In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows is false. False Claims Act: What you need to know and understand to avoid violations.

9. An example of this may include a government contractor who submits records that he knows (or should know) is false and that indicate compliance with certain contractual or regulatory requirements. • Instances in which someone obtains ineligible money from the federal government; meanwhile using false statements or records in order to retain the money. • “Reverse false claim” may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year avoiding the act of refunding the money to Medicare. Examples of Violations to the False Claims Act.

10. FCA claims are brought as qui tam actions, which allows private plaintiffs to sue on behalf of the U.S. government and receive a portion of the recovered fund if successful. Qui tam actions

11. A weapon used in the fight against fraud and abuse is the Anti-Kickback statutes, which prohibits the solicitation , including kickbacks and rebates in the exchange for referrals of federally program services. Anti-Kickback statutes

12. Under the physician self-referral prohibitions are the Stark I and Stark II laws. Physician self-referral prohibitions

13. Stark I The physician is barred from referring Medicare patients to a designated clinical laboratory in which the physician or immediate family member possesses a financial interest. Statute I

14. Stark II A physician cannot refer Medicare patients to a designated health service in which the physician or immediate family member possesses a financial interest. The designated service is broad to include DME, clinical laboratory, OT, PT, orthotics and prosthetics, radiology, parenteral, and enteral nutritional service, HH services, and outpatient prescription drugs. Statute II

15. Utilizing the federal mail and wire systems while involved in fraudulent and abusive behavior will violate statutes which prohibit the use of the U.S. Postal Service or commercial wire services for the advancement of a scheme relating to the fraud and abuse. Mail and wire fraud statutes

16. The increased penalties and new enforcement mechanisms are part of the Health Insurance Portability and accountability Act (HIPAA) focus on fraud and abuse. • HIPAA modifies the civil money penalty law and provides enhanced resources for the federal government to combat fraud. This includes penalties for actions related to such activities as unbundling, upcoding, seeking reimbursement after being excluded from the participation in Medicare or Medicaid programs. HIPAA

17. Fraud and Abuse Control Program • Medicare Integrity Program • Beneficiary Incentive Program • Health-Care Fraud and Abuse Data Collection Program HIPAA’s Fraud Enforcement Programs

18. Physicians at Teaching Hospitals • 72-Hour Rule • Hospital Outpatient Laboratory Project • PPS Patient Transfer Project OIG Fraud and Abuse Initiatives

19. Written standards of conduct and policies and procedures • Chief Compliance Officer to oversee the program • Effective education and training programs • Process for receiving complaints of violation • A system that responds to allegation or illegal activities and the enforcement of disciplinary actions through a well-publicized disciplinary directives. • Audits and evaluation techniques to monitor compliance • Investigation and corrective action of the identified problems Coding Compliance Programs

20. You cannot be fired for any reason that would put Ohio’s public policy in danger, for example:  • reporting illegal activities • reporting unsafe conditions • testifying against an employer • filing a workers’ compensation claim • suing over wages • consulting an attorney for advice about a possible lawsuit Ohio WhistleblowerProtection Act?

21. How can you contact us? • Telephone: 703 292-7100 • OIG Anonymous Hotline: 1-800-428-2189 • Fax: 703 292-9158/9159 • E-mail Hotline: oig@nsf.gov • Write: National Science Foundation Office of Inspector General 4201 Wilson Boulevard Arlington, VA 22230

22. Abelson, Reed. “U.S. Settles Accusations That Doctors Over treated.” New York Times. (January 4, 2013). From: http://www.nytimes.com/2013/01/05/business/us-settles-accusations-that-doctors-overtreated.html?_r=0 • Department of Justice. “EMH Regional Medical Center and North Ohio Heart Center to pay $4.4 million to resolve False Claims Act Allegations.” Department of Justice. (January 4, 2013). From: http://www.justice.gov/usao/ohn/news/2013/04janemh.html • North Ohio Heart. “North Ohio Heart Reaches Settlement; Continues to Provide High-Quality Cardiac Care.” Ohio Medical Group. (January 4, 2013). From: http://blog.partnersforyourhealth.com/Blog/bid/93734/North-Ohio-Heart-Reaches-Settlement-Continues-to-Provide-High-Quality-Cardiac-Care Examples of Court Cases resulting from Fraud and Abuse issues.

23. California Health Care Foundation.(Sept. 25, 2012). Federal Officials Warn Hospitals About Using EHRs for 'Upcoding‘. Retrieved from http://www.californiahealthline.org/articles/2012/9/25/federal-officials-warn-hospitals-about-using-ehrs-for-upcoding.aspx#ixzz2R39tkvft • McWay, D. (2010). Legal and Ethical Aspects of Health Information Management. (3rd, ed.).Delmar, Clifton Park, NY. pp307-318. • Office of the Inspector General (2012). Health Care Fraud and Abuse Control Program Report.Retrieved from http://oig.hhs.gov/reports-and-publications/hcfac/index.asp • The National Health Care Anti-Fraud Association.(Jan. 2013). Health Care Fraud & Abuse Control Report for Fiscal Year 2012. Retrieved from http://www.nhcaa.org/news/health-care-fraud-abuse-control-report-for-fiscal-year-2012.aspx References