Health Care Fraud and AbuseIntegrated Delivery System (IDS)

Prepared by Marion County CAPSfor use with IDS Providers

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Training Requirements

• As a member of the IDS, this Provider is required by Federal Mandate to make available Fraud & Abuse Training to employees and contracted providers

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Fraud and Abuse Policy

• It is the policy of MVBCN, CAPS & IDS Providers to:– Review and investigate all allegations of fraud

and/or abuse, whether internal or external;– Take corrective actions for any supported

allegations after a thorough investigation; and– To report confirmed misconduct to the

appropriate parties and/or Agencies– Follow all applicable laws, rules, and policies

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Whose Problem Is It?• Health Care Fraud Impacts Everyone

– While one in four American say it’s OK to defraud insurers, consumers need to understand this type of

thinking is costly and results in rising health care costs • The average American household pays $1,000

every year in out-of-pocket-costs as a result of insurance fraud

• Seniors and taxpayers pay up to $1 billion a year in inflated drug prices due to potential fraud and loopholes in Medicare, representing 1/5 of Medicare spending in 2000

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Defining the Problem• What is FRAUD?

– The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person

• What is ABUSE?– Practices that are inconsistent with sound fiscal, business,

or medical practices and result in an unnecessary cost to Medicaid, Medicare or the MVBCN, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care

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Types of Fraud• Examples include:

– Billing for services not provided (i.e. phantom services), billing for “no shows”

– Misrepresenting the diagnosis to justify the service– Misrepresenting the type or place of service, or who

rendered the service– Duplicate billing or billing for non-covered services– Substitution of services– Incorrect coding or “up-coding” to generate more revenue– Inappropriate documentation for services rendered– Over or Under-utilization– Denying or limiting access to services/benefits

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Potential Fraud Indicators• Examples include:

– Limited time spent by providers with patients

– Inadequate treatment plan

– Consistently poor outcomes may be a sign of lack of treatment

– Unusual patient encounter ratios

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What Laws Regulate Fraud?• False Claims Act (FCA)

• HIPAA

• Deficit Reduction Act

• The False Claims “Whistleblower” Employee Protection Act

• Administrative Remedies for False Claims and Statements

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False Claims Act• Under the False Claims Act (FCA), 31 U.S.C

3729-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim– The FCA applies to any health care entity that

receives more than $5 million in Medicaid funds • MCHD receives in excess of $5 million annually

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HIPAA• The Health Insurance Portability and

Accountability Act (HIPAA), 45 CFR, Title II, 201-250, provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties and sanctions for noncompliance

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Deficit Reduction Act• The Deficit Reduction Act (DRA), Public Law

No. 109-171, 6032, passed in 2005, is designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries

• The Act requires compliance for continued participation in the programs. The development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing fraud & abuse must be implemented

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Whistleblower Protection• The False Claims Act Whistleblower Employee

Protection Act, 31 U.S.C 3730(h), states that a company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer

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Administrative Remedies• Administrative Remedies for False Claims and

Statements, 31 U.S.C Chapter 8, 3801, states that any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim

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Authority to Pursue• DHS and other health oversight entities are not

limited in their authority to pursue legal redress for fraud and abuse to the fullest extent of the law

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Our Anti-Fraud Strategy• Elements include:

– Prevention– Education and Training– Detection and Investigation– Reporting Fraud

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Prevention & Education

• Education:– Fraud prevention education and training of

employees, contractors, and providers– Designed to heighten awareness of requirements

and consequences

• Programmatic Elements:– Identify high risk operational areas– Implement needed controls– Conduct on-going monitoring and audits

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Detection and Investigation

• Detection:– Treatment record reviews and chart audits– Routine billing claim audits– Ongoing monitoring of key measures

• Investigation:– Preliminary research on all allegations, whether

internal or external– Determine if there is “suspicious activity”– Medical record audits

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Reporting Fraud

• Reporting:– Providers

• Suspected fraud and/or abuse

• Probable or confirmed fraud and/or abuse

– Members• Suspected or verified fraud and/or abuse

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Corrective Action and Discipline

• Corrective Action and Discipline:– Corrective action will proceed as outlined within

our employee disciplinary guidelines

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This Provider’s Responsibilities

• Credential all staff• Staff disclosure of conflict of interest• Disciplinary guidelines for staff• OHP Member complaints and appeals• Audit charts and billing/claims data• Repayment and data correction procedures• Controls on staff access to resources• Train all staff on the MVBCN’s Prevention

and Detection of Fraud and Abuse policy

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Tips for Compliance• Maintain appropriate documentation• Record start and stop time• Understand which services are covered vs.

non-covered (i.e. non-billable)• No duplicate claims• Maintain legible records• Comply with State licensure regulations• Cooperate with any audits or reviews• Avoid ‘up-coding’ or ‘down-coding’

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Reporting Fraud and Abuse

• All reports of Fraud and Abuse will utilize the same procedure developed by the MVBCN– Telephone (866) 370-5525 (not yet functional)– Mail– Secure internet (not yet functional)

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Resources

• MVBCN– Prevention and Detection of Fraud and Abuse Policy– MVBCN's Orientation of OHP Contractors' Complicance

Officers PowerPoint• CAPS

– Fraud and Abuse Policy, IDS Handbook– CAPS website (http://www.co.marion.or.us/HLT

/CAPS/provider_resources/fraudandabuse.htm)• DHS

– Office of Payment Accuracy and Recovery (http://www.oregon.gov/DHS/aboutdhs/fraud/)