Medicare Fraud, Waste and Abuse:
Prevention, Detection and Reporting
January 2013
Objectives
• Explain obligation of everyone to detect, prevent,
and correct fraud, waste, and abuse (“FWA”)
• Provide information on how to report FWA
• Provide information on laws pertaining to FWA
• Meet the regulatory requirement for training and
education.
Definitions-Fraud, Waste and Abuse
To understand the program requirements related to FWA the following
are definitions of each term:
Fraud-Intentional deception or misrepresentation to obtain
the money or property of a health care benefit program by
means of false or fraudulent pretenses, representations or
promises
Waste-The over-utilization of services or other practices
that result in unnecessary costs.
Abuse-Obtaining payment for items or services when there
is no legal entitlement to that payment, but without
knowing or intentional misrepresentation of facts to
obtain payments.
Criminal Fraud
Knowingly and willfully executing, or
attempting to execute, a scheme or artifice to
defraud any health care benefit program; or
to obtain, by means of false or fraudulent
pretenses, representations, or promises, any
of the money or property owned by, or under
the custody or control of, any health care
benefit program.
18 United States Code §1347
Waste and Abuse
Requesting payment for items and services
when there is no legal entitlement to
payment. Unlike fraud, the provider has
not knowingly or intentionally
misrepresented facts to obtain payment.
Differences Between Fraud,
Waste and Abuse
There are differences between fraud, waste,
and abuse. The primary difference is intent
and knowledge. Fraud requires the person
to have an intent to obtain payment and the
knowledge that the actions are wrong.
Waste and abuse may involve obtaining an
improper payment, but does not require the
same intent and knowledge.
Medicare Fraud, Waste and Abuse:
Laws
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False Claims Act
Anti-Kickback Statute
Physician Self-Referral (Stark)
Criminal Health Care Fraud Statute
False Claims Act (FCA)
Prohibits:
• Presenting a false claim for payment or approval;
• Making or using a false record or statement in support of a false
claim;
• Conspiring to violate the False Claims Act;
• Falsely certifying the type or amount of property to be used by
the Government;
• Certifying receipt of property without knowing if it’s true;
• Buying property from an unauthorized Government officer; and
• Knowingly concealing or knowingly and improperly avoiding or
decreasing an obligation to pay the Government.
31 United States Code § 3729-3733
Anti-Kickback Statute
Prohibits:
Knowingly and willfully soliciting, receiving,
offering or paying remuneration (including any
kickback, bribe, or rebate) for referrals for
services that are paid in whole or in part under
a federal health care program.
42 United States Code §1320a-7b(b)
Physician Self-Referral Law
(Stark)
Prohibits:
Physicians from making a referral for certain
designated health services to an entity in which
the physician (or a member of his or her
family) has an ownership or investment
interest or with which he or she has a
compensation arrangement (exceptions apply).
42 United States Code §1395nn
Criminal Health Care Fraud Statute
Prohibits:
• Knowingly and willfully executing, or attempting
to execute a fraudulent scheme or artifice; and
• Defrauding any health care benefit program or
obtaining by means of false or fraudulent
pretenses, representations or promises, any of
the money or property owned by or under the
custody or control of any health care benefit
program.
Medicare Fraud, Waste and Abuse:
Penalties
• Civil Monetary Penalties
• Criminal Sanctions
• Exclusions
Civil Monetary Penalties
• Up to $10,000 to $50,000 per violation
• Assessment up to 3 times the amount
depending on seriousness
Criminal Sanctions
• Criminal Prosecution and Conviction for
health care fraud
• Follow Federal Sentencing Guidelines
Exclusions
Mandatory
Permissive
• Exclusion from participation in
all Federal health care
programs for:
– Medicare Fraud
– Patient abuse or neglect
• Other health-care related fraud,
theft or financial misconduct
• Unlawful manufacture,
distribution prescription or
dispensation of controlled
substances.
•Misdemeanor convictions
for:
– Health care fraud
– Controlled substances
• Fraud for non-health care
program
• License suspension or
revocation
•Obstruction of investigation
Excluded Individuals and Entities
Providers and contracting entities must check
exclusion status before employment or contractual
relationships
• OIG List of Excluded Individuals and Entities (LEIE)
• General Services Administration (GSA) database of
excluded individuals and entities (EPLS)
Medicare Fraud, Waste and Abuse:
Prevention Tools
• Enhanced Medicare enrollment
– Fees
– Screenings
– Revalidations
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Automated Claims Edits
Predictive Analytics
Suspension of Payments
Education
CMS and State and Federal Law
Enforcement Agencies
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Office of the Inspector General
Federal Bureau of Investigation
Department of Justice
Medicaid Fraud Control Unit
CMS Contracted Agencies
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Comprehensive Error Rate Contractors
Recovery Audit Contractors
Program Safeguard Contractors
Zone Program Integrity Contractors
Medicare Drug Integrity Contractors
Medicare Audit Contractors
Medicare Fraud, Waste and Abuse:
Detection
Government Uses:
• Data
• Claim and Medical Reviews
Data
• Target high-risk areas
• Services, geographic locations, and provider
types
• Outlier providers that bill differently in a
statistically significant way
• Integrated Data Repository
Claim Reviews
• CMS
• Contracted Entities
• Private Payers
Medical and Claims Reviews
Entities that conduct Medical Reviews to
reduce payment errors by identifying and
addressing provider coverage and coding
errors.
• Medicare Contractors
• Medicare Audit Contractors
• State Contractors
Provider’s Role
• Provide only medically necessary, high
quality services
• Properly document all services
• Correctly code and bill for services
• Check exclusion lists
• Comply
Please Report Concerns
• Talk to your supervisor or manager
• Share your concerns with the Compliance Officer in
person, in writing or by phone. Call Greg Wendorf
at 608-756-6811 or John Cook at 608-756-6642
• Call the Compliance Hotline (anonymous) toll-free
at 877-647-6464. the Hotline is answered 24 hours
a day, 365 days a year
• Report on the Internet;
mercyhealthsystem.alertline.com
Reporting to Government
HHS Hotline
• Report to HHS OIG Hotline
• Phone: 1-800-HHS-TIPS (1-800-447-8477)
TTY: 1-800-377-4950
Fax: 1-800-223-8164
• E-mail: HHSTips@oig.hhs.gov
• Mail: Office of Inspector General
Department of Health and Human Services
Attn: Hotline
P.O. Box 23489
Washington, DC 20026
Reporting to Government
OIG Provider Self-Disclosure
Protocol
• Disclose issues to OIG
• Avoid costs and disruptions
• OIG works cooperatively
CMS Self-Referral Disclosure
Protocol
• Report actual or potential violations of
Physician Self-Referral Law (Stark Law)
• Not used to obtain a CMS determination
• Submit with intent to resolve overpayment
Reporting to Government
Other
Medicare Fraud, Waste and Abuse:
Post-Assessment
1.
Your job is to code a diagnosis to bill Medicare purposes of
payment. As part of this job you are to verify, through a
certain process, that the data is accurate. You find data is
inaccurate but your physician tells you to ignore diagnosis
codes for these individuals. What do you do?
A.
B.
Do what is asked by your physician
Report the incident to the Compliance Department
(via compliance hotline or other mechanism)
Discuss concerns with immediate supervisor
Contact law enforcement
C.
D.
Medicare Fraud, Waste and Abuse:
Post-Assessment
2.
Billing insurance claims for prescription drugs that were not
prescribed by any doctors and were not dispensed to any
customers.
The law or statute that is violated in this example would be the:
A. False Claims Act
B. Stark Law
C. Anti-Kickback Statute
D. Federal Drug Administration (FDA) Prescription Law
Medicare Fraud, Waste and Abuse:
Post-Assessment
3. Medicare abuse includes any practice that is not
consistent with the goals of providing patients with
all needed services they request, meeting
professionally recognized standards, and charging
fair prices.
A. True
B. False
Medicare Fraud, Waste and Abuse:
Post-Assessment
4. Suspected fraud and abuse may be reported anonymously
to the Office of Inspector General (OIG) via ________.
A.
B.
C.
D.
Phone or fax.
E-mail or posted mail.
OIG website.
All of the above.
Medicare Fraud, Waste and Abuse:
Post-Assessment
5. Medicare fraud is any act that results in
unnecessary costs to the Medicare Program.
A. True
B. False
Medicare Fraud, Waste and Abuse:
Post-Assessment
6. When entering information on a claim, an employee
transposes digits on an HICN (Health Insurance Claim
Number) and submits a claim containing erroneous
information. This would be considered:
A.
B.
C.
D.
Fraud
Waste
HICN Violation
Abuse
Medicare Fraud, Waste and Abuse:
Post-Assessment
7. The best entity for health care providers to selfdisclose Medicare fraud or abuse to is the ________.
A.
B.
C.
D.
Local police department.
Office of Inspector General (OIG).
General Services Administration (GSA)
Comprehensive Error Rate Testing (CERT)
Program.
Medicare Fraud, Waste and Abuse:
Post-Assessment
8. Possible penalties for Medicare fraud or abuse include
_______.
A. Imprisonment in criminal cases.
B. Civil Monetary Penalties (CMPs) up to $50,000 per
violation.
C. Exclusion from participation in all Federal health care
programs.
D. All of the above.
Medicare Fraud, Waste and Abuse:
Post-Assessment
9. The main authorities that address fraud and
abuse are the ________.
A.
B.
C.
D.
E.
F.
False Claims Act (FCA).
Anti-Kickback Statute.
Physician Self-Referral Law (Stark Law).
Social Security Act.
U.S. Criminal Code.
All of the above.
Medicare Fraud, Waste and Abuse:
Post-Assessment
10. The acronym CERT in the Medicare Program stands for:
A.
B.
C.
D.
Comprehensive Education and Re-Training
Complete Evaluation Record Tracking
Criminal Emergency Response Team
Comprehensive Error Rate Testing