WHATS NEW in HEALTHCARE REFORM
Who are the PLAYERS
What are the SCHEMES
Where are the CFE JOBS
CT ACFE Presentation - Marcia
Silva
October 6, 2010
1
Fraud, waste and abuse takes an enormous toll
on government budgets. More than $98
billion was lost to improper payments in
fiscal year 2009 alone, according to the
Federal Office of Management and Budget. .
CT ACFE Presentation - Marcia
Silva
October 6, 2010
2
Fraud
 Fraud is the intentional deception or misrepresentation
made by a person with the knowledge that the deception
could result in some unauthorized benefit to themselves
or someone else. It includes any act that constitutes fraud
under applicable federal or state laws.
Abuse
 Abuse includes incidents or practices of providers that are
inconsistent with sound fiscal, business or medical
practices, and result in an unnecessary cost to the
Medicaid Program, Immunization Program, or a health
insurance company. Abuse also includes reimbursement
for services that are not medically necessary or that fail to
meet professionally recognized standards for health care.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
3
Payments made through Medicare/Medicaid/private insurers are made
through codes (RUGs, HCPCS, ICD9, Revenue Codes, DRGs)
National Coverage Determinations, Local Coverage Determinations
This creates opportunity!
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Pay and Chase – Postpay review of claims
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Review of Red Flags on Applications
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Edits in systems to stop payments
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Data Analysis – Peer Analysis –
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Tips – Whistleblowers – Recipients - Complaints
CT ACFE Presentation - Marcia
Silva
October 6, 2010
4
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The new healthcare reform law places a heavy
emphasis on the increased use of information
technology (IT) to improve the American
healthcare system.
With new technology means greater
opportunity for fraud!
CT ACFE Presentation - Marcia
Silva
October 6, 2010
5
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The law identifies health information
technology as a substantial part of mandates
for coordination of care for the chronically ill,
development of the patient-centered medical
home care delivery model and the
advancement of telehealth, particularly
patient monitoring.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
6
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Also, since the health reform bill will bring
millions of new consumers into the system,
the reform law will foster changes in marketwide guidelines and individual state
regulations governing health information
exchanges.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
7
Penalties
New penalties for willful neglect of compliance are mandatory and start at
$10,000 Minimum. The HITECH Act within the American Recovery and
Reinvestment Act of 2009 (ARRA) includes a number of changes to how the
HIPAA regulations will be enforced and the penalties that will be applied.
HIPAA can now apply directly to individuals in cases of wrongful disclosure.
Add to this the fact that HIPAA compliance will now be actively audited by the
Department of Health and Human Services Office for Civil Rights (OCR), and
full compliance with HIPAA becomes a very serious issue.
Self-auditing your HIPAA compliance before OCR does it for you is now an
essential part of the avoidance of these penalties.
The icing on the cake is that now state attorneys general can now also bring civil
action in federal court under HIPAA.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
8
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HIPAA violation lands an employee federal prison time; Red Flag rules a
go for June 1.
When training staff about the dangers of accessing people’s medical
records without a legit reason, you might cite a recent case as a
cautionary tale.
A hospital researcher recently received a four-month federal prison
sentence for looking at patients’ medical records that didn’t apply to his
line of work.
The former employee at the UCLA School of Medicine accessed patient
records at the hospital over 300 times during a three-week period,
mostly to peek at the private health records of celebrities, according to a
Department of Justice release.
In his plea agreement, the employee “acknowledged that at the time he
viewed these patients’ medical information, he had no legitimate reason,
medical or otherwise, for obtaining the personal information,” the DOJ
says. The DOJ investigators did not find any evidence that the employee
attempted to use or sell the information that he accessed – he
apparently sought the information out of curiosity.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
9
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Incentives are given for the use of EHRs but
there are also issues:
Cloning – copy and paste function (from one
record to the next (did it happen?)
Approval – who is creating the record,
approving the actions taken (signature
authentication.)
How does it impact fraud investigators
CT ACFE Presentation - Marcia
Silva
October 6, 2010
10
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Identity Theft –Beneficiary (role of SMP)
(picture IDs need to be shown)
ID Theft – Provider Level
Duplicate Billing – Systems not talking to each
other – Medicaid/Medicare/Privates
CT ACFE Presentation - Marcia
Silva
October 6, 2010
11
Reading your EOB
Double Billing
Mary J. visited her primary care physician (PCP) and had a chest
X-ray because of a chronic cough. Her PCP sent the X-ray to a
radiologist to be read. The following month Mary got her EOB
and a bill from the radiologist. When she looked at her EOB she
noticed that both her PCP and the radiologist billed her
insurance company to read the X-ray. The insurance company
rejected the claim from the radiologist.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
12
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Disgruntled employees
Bad Suppliers
Family members
Billing Companies
Career Criminals
Organized structure groups
CT ACFE Presentation - Marcia
Silva
October 6, 2010
13
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Wrong Diagnosis or Procedure
Betsy D. went to her PCP for a sore throat. When she received
her EOB she noticed that instead of billing for a throat culture,
her doctor’s office had mistakenly billed for a diabetes blood
test. The computer program used by her doctor’s billing
company automatically put down a diagnosis of diabetes, which
Betsy does not have.
Although there may be no financial mistake, Betsy very wisely
called her health plan and doctor’s office to correct the diagnosis
error. In the future, if she wanted to purchase health insurance,
she could be denied because she had been diagnosed with
diabetes. Or, if not denied, a new health plan could impose a
pre-existing condition waiting period
CT ACFE Presentation - Marcia
Silva
October 6, 2010
14
1-800 – Medicare (1-800-633-42273)
SMP ( Senior Medicare Patrol)
Dept of Public Health (www.ct.gov/dph)
HHS OIG - Phone: 1-800-HHS-TIPS
(1-800-447-8477)
Fax:
1-800-223-8164
Mail:
Office of Inspector General
Department of Health and Human Services
ATTN: HOTLINE
PO Box 23489
Washington, DC 20026
CT ACFE Presentation - Marcia
Silva
October 6, 2010
15
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Miscalculating Your Coinsurance Amount
Max had outpatient surgery on his hand. He is in a PPO
and he pays a coinsurance of 20% for outpatient
procedures. Following the surgery, he was sent a bill
from the surgeon’s billing company for $1000, 20% of
the surgeon’s $5000 bill. However, when Max received
his EOB, he noted that although the surgeon billed
$5000, he was paid only $3000 by his health plan.
Max did the math and figured that he should
be paying 20% of $3000, not 20% of $5000.
His health plan confirmed that was correct
and he was able to pay out $600 instead of
$1000.
CT ACFE Presentation - Marcia
Silva
October 6, 2010
16
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The U.S. Department of Health & Human Services manages a
robust website intended to inform consumers about the new
law: HealthReform.GOV
The Obama Administration has created a website which aims
to explain the new health reform law: Health Reform: What It
Means To You
CT ACFE Presentation - Marcia
Silva
October 6, 2010
17
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ZPIC Contractors (Zone Program Integrity Contractors) (Investigators,
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MAC Contractors (Pay Medicare Claims)
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RAC Contractors -Recovery Audit Contractors are paid by
percentage for what they find – bounty hunters)
medical reviewers, data analysts)
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Region A:
Diversified Collection Services
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Region B:
Region C:
CGI
http://racb.cgi.com
Connolly, Inc.
www.connollyhealthcare.com
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Region D: HealthDataInsights
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www.dcsrac.com
http://racinfo.healthdatainsights.co
CT ACFE Presentation - Marcia
Silva
October 6, 2010
18
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MIC Contractors (Review MICS)
(analyze Medicaid claims data) Who are they (Advance Med Corporation; ACS
Healthcare Analytics, Inc.; Thomson Reuters; Safeguard Services, LLC; and
IMS Government Solutions)
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MIC Contractors (Audit MICS)
(conduct post-payment audits of all types of Medicaid providers) Who are
they: (Booz Allen Hamilton; Fox Systems, Inc.; IPRO; Health Management
Systems; and Health Integrity, LLC)
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MIC Contractors (Education MICS)
(work with the Review and Audit MICS to educate health care providers and
state Medicaid officials; Who are they: Information Experts; and Strategic
Health Solutions)
CT ACFE Presentation - Marcia
Silva
October 6, 2010
19
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Federal Law Enforcement (CMS,HHS-OIG, FBI
(analysts, investigators, Dept of Treasury,
Postal Service))
State law enforcement (Chief States Attorney,
Attorney General, MFCU)
State Regulatory Agencies (DMHAS, DSS, DPH)
CT ACFE Presentation - Marcia
Silva
October 6, 2010
20
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Contact Information:
Marcia Silva, CFE, AHFI
860-622-4800
Marcia.Silva@hp.com
CT ACFE Presentation - Marcia
Silva
October 6, 2010
21