- Billing for services or supplies that were not provide
- Unbundling (i.e., coding components of a procedure separately when only a single code is necessary)
- Upcoding (i.e., coding and billing for a level of service that is not supported by the medical record documentation
- Falsifying a diagnosis in order to get paid for services
- Altering claims to obtain more money
- Submitting duplicate claims to receive additional money
- Completing Certificate of Medical Necessity forms when necessity is not supported by the medical record
- Soliciting, offering, or receiving kickbacks, bribes, or rebates
- Submitting claims involving collusion between a provider and a patient
- Over-utilizing services
- Billing for non-covered services
- Signing blank prescriptions
- Making excessive referrals to an ancillary facility
The FBI can investigate federal and private payer cases of fraud, but has no jurisdiction to impose sanctions on providers. Anytime there is a question regarding a service performed or a diagnosis given, it is best to clarify it with the physician before keying information into the computer.
WHAT IS ABUSE?
Abuse is an incident or practice that is not consistent with sound medical, business, or fiscal practices.
Examples include providing medically unnecessary care, or care that does not meet the standards of care. It is considered abuse when Medicare reimburses for services or items for which the provider is not entitled to compensation. Abuse is similar to fraud except it cannot be proven that the abusive acts where committed knowingly, willingly, and intentionally. To determine whether a practice is guilty of abuse, answer the following questions:
- Is the service or supply necessary?
- Is the service or supply appropriate according to professionally recognized standards?
- Has a fair price been charged?
SOME CRIMINAL STATUTES RELATING TO FRAUD AND ABUSE
FALSE STATEMENTS RELATING TO HEALTH CARE MATTERS
It is a crime to knowingly and willfully falsify or conceal a material fact or to make any false statement or use any false writing or document in connection with the delivery of health care or relating to health care payment for items or services. For example, billing for any service that wasn’t performed is considered fraud. Penalties could include fines and imprisonment for up to 5 years. This law applies to claims filed with most third-party carriers.
OBSTRUCTION OF CRIMINAL INVESTIGATIONS OF HEALTH CARE OFFENSES
It is a crime to willfully prevent, obstruct, mislead, or delay or to attempt to prevent, obstruct, mislead, or delay the communication of records relating to a federal health care offense. For example, if the OIG requests copies of records, the request cannot be ignored by the physician’s office manager. Penalties for this obstruction could result in fines and imprisonment for up to 5 years. This law applies to claims filed with most third-party carriers.
MAIL AND WIRE FRAUD
It is a crime to use a mail, courier, or wire service to conduct a scheme to defraud another of money or property. The term wire services include the use of a telephone, fax machine, or computer. Every time one of these services is used, it is considered a separate violation punishable by fines and imprisonment for up to 5 years. Consider a gerontologist who bills for services to nursing home patients but did not perform the services. If these claims were submitted to Medicare and Medicaid electronically, the physician is guilty of mail and wire fraud.
THEFT OR EMBEZZLEMENT IN CONNECTION WITH HEALTH CARE
It is a crime to knowingly and willfully embezzle, steal, or intentionally misapply any of the assets of a health care benefit program. For example, an office manager embezzled some Medicare checks and doctored the books so they would not be missed. Since he deposited the monies from the federal government into his own account, he can now be punished by fines and imprisonment for up to 10 years if the amount embezzled was $100 or more, or fines and imprisonment up to 1 year if less than $100. This law applies to claims filed with most third-party carriers.
FRAUD AND ABUSE CONTROL PROGRAM
The Fraud and Abuse Control Program was established by the federal government under subtitle A of HR 3103. The Office of Inspector General (OIG), Federal Bureau of Investigation (FBI), and Department of Justice (DOJ) share in the prosecution and investigation of suspected fraud and abuse. The OIG investigates fraud cases that involve federal programs such as Medicare, Medicaid, and Child
Health Grant programs. The OIG can impose civil monetary penalties and program exclusions on providers guilty of fraud. The FBI investigates federal and private payor cases of suspected fraud, but does not have the authority to impose sanctions on providers. Both the OIG and the FBI refer cases to the DOJ, which prosecutes fraudulent providers for violations of any criminal laws.
The responsibilities of this fraud and abuse control program are as follows:
- To investigate and audit the delivery of medical services and payments associated with those services
- To facilitate enforcement of statutes
- To provide education to providers through fraud alerts and advisory opinions
- To share information with public and private third-party payers
