While chasing fraudulent payments after the fact has been standard practice, the Centers for Medicare & Medicaid Services (CMS) and forward-thinking state agencies are adopting new technologies and practices that allow them to prevent fraud before it happens by proactively identifying high-risk providers and suspicious claims.
Full Answer
How can we prevent Medicare and Medicaid provider fraud?
The creation of a standardized, rigorous registration process for Medicare and Medicaid providers is one of the greatest opportunities for fraud prevention. CMS has implemented the Automated Provider Screening (APS) system in an effort to identify high-risk providers; meanwhile, each state has its own system for onboarding.
What are the Medicare fraud and abuse laws?
These laws specify the criminal, civil, and administrative penalties and remedies the government may impose on individuals or entities that commit fraud and abuse in the Medicare and Medicaid Programs.
Why do we need laws to combat health care fraud and abuse?
Health care professionals who exploit Federal health care programs for illegal, personal, or corporate gain create the need for laws that combat fraud and abuse and ensure appropriate, quality medical care. Physicians frequently encounter the following types of business relationships that may raise fraud and abuse concerns:
What are the best practices for preventing healthcare fraud?
Through its extensive work with agencies, Dun & Bradstreet developed three best practices to proactively address healthcare fraud: 1. Deploying Standardized Registration Processes The creation of a standardized, rigorous registration process for Medicare and Medicaid providers is one of the greatest opportunities for fraud prevention.
How can Medicare fraud be prevented?
There are several things you can do to help prevent Medicare fraud.Protect your Medicare number. Treat your Medicare card and number the same way you would a credit card number. ... Protect your medical information. ... Learn more about Medicare's coverage rules. ... Do not accept services you do not need. ... Be skeptical.
Who enforces Medicare fraud?
Government agencies, including the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare and Medicaid Services (CMS), enforce these laws.
How does CMS fight fraud and abuse?
CMS continues to work with beneficiaries and collaborate with partners to reduce fraud, waste, and abuse in Medicare, Medicaid and CHIP. The Senior Medicare Patrol (SMP) program, led by the Administration on Aging (AoA), empowers seniors to identify and fight fraud.
How does fraud and abuse negatively impact or further burden our healthcare system?
How does Fraud, Waste and Abuse Affect You? Fraud, waste and abuse diverts significant resources away from necessary health care services, which results in paying higher co-payments and premiums, and other costs. Fraud can also impact the quality of care you receive and even deprive you of some of your health benefits.
What are government enforcement actions?
Criminal, civil or administrative legal actions relating to fraud and other alleged violations of law, initiated or investigated by OIG and its law enforcement partners.
How can healthcare fraud be controlled?
How Can I Help Prevent Fraud and Abuse?Validate all member ID cards prior to rendering service;Ensure accuracy when submitting bills or claims for services rendered;Submit appropriate Referral and Treatment forms;Avoid unnecessary drug prescription and/or medical treatment;More items...
What was developed by the federal government to reduce or eliminate fraud in healthcare?
Fact sheet. The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud. Since inception in 1997, the Health Care Fraud and Abuse Control (HCFAC) Program has been at the forefront of the fight against health care fraud, waste, and abuse.
Does the government play a role in the increase of fraud and abuse in healthcare?
Recently, the U.S. Department of Justice announced “the largest ever health care fraud enforcement action,” charging 412 people with crimes totaling around $1.3 billion in false billings. Many of the charges were related to the prescription and distribution of opioids, according to the Washington Post.
Which of the following is considered the best defense under the Medicare Integrity Program?
Which of the following is considered the best defense under the Medicare Integrity program? Having a strong compliance plan.
How can healthcare leaders reduce fraud and abuse?
To prevent an organization from participating in healthcare fraud and abuse activities, providers should understand key healthcare fraud laws, implement a compliance program, and improve medical billing and business operations processes.
How does healthcare fraud impact government spending?
Costs of Fraud and Abuse The Federal Bureau of Investigation estimates that fraudulent billing—the most serious of program integrity issues—constitutes 3% to 10% of total health spending, contributing to inefficiency, high health care costs, and waste.
How does Medicare fraud affect the economy?
The Effects on Your Organization Fraud perpetrated against the Medicare and Medicaid systems directly drains the taxpayers of this country. Medicare is funded through a payroll tax on both the employer and employee. As more funds are needed, taxes are raised. Thus, everyone employed is affected.
What is strike force?
The strike forces are interagency teams of prosecutors and special agents that focus enforcement resources on geographic areas at high risk for fraud. CMS has made claims data available more quickly and efficiently by providing law enforcement increased access to data, including real-time data.
Does CMS require MCEs?
As States increasingly use managed care to deliver Medicaid services, CMS should require that State contracts with managed care entities (MCEs) include a method to verify with beneficiaries whether services billed by providers were received, and CMS should update guidelines to reflect current concerns expressed by MCEs and States.
What is heat in Medicare?
The DOJ, OIG, and HHS established HEAT to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent and detect fraud and abuse . HEAT expanded the DOJ-HHS Medicare Fraud Strike Force, which targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.
What is the role of third party payers in healthcare?
The U.S. health care system relies heavily on third-party payers to pay the majority of medical bills on behalf of patients . When the Federal Government covers items or services rendered to Medicare and Medicaid beneficiaries, the Federal fraud and abuse laws apply. Many similar State fraud and abuse laws apply to your provision of care under state-financed programs and to private-pay patients.
What is the Stark Law?
Section 1395nn, often called the Stark Law, prohibits a physician from referring patients to receive “designated health services” payable by Medicare or Medicaid to an entity with which the physician or a member of the physician’s immediate family has a financial relationship , unless an exception applies.
What is the OIG exclusion statute?
Section 1320a-7, requires the OIG to exclude individuals and entities convicted of any of the following offenses from participation in all Federal health care programs:
What is CMPL 1320A-7A?
The CMPL, 42 U.S.C. Section 1320a-7a, authorizes OIG to seek CMPs and sometimes exclusion for a variety of health care fraud violations. Different amounts of penalties and assessments apply based on the type of violation. CMPs also may include an assessment of up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, paid, solicited, or received. Violations that may justify CMPs include:
What is the OIG self disclosure protocol?
The OIG Provider Self-Disclosure Protocol is a vehicle for providers to voluntarily disclose self-discovered evidence of potential fraud. The protocol allows providers to work with the Government to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.
Is there a measure of fraud in health care?
Although no precise measure of health care fraud exists, those who exploit Federal health care programs can cost taxpayers billions of dollars while putting beneficiaries’ health and welfare at risk. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of beneficiaries.
How is original Medicare claims analyzed?
Original Medicare claims will be analyzed using innovative risk scoring technology that applies effective predictive models, an approach similar to that used by the private sector to successfully identify fraud.
When will CMS start using predictive modeling?
On the heels of the White House launch of the Campaign to Cut Waste - an administration wide initiative to crack down on waste, fraud and abuse, the Centers for Medicare & Medicaid Services (CMS) announced today that starting July 1 , it will begin using innovative predictive modeling technology to fight Medicare fraud.
How to obtain a complete view of potentially fraudulent behavior?
To obtain a complete view of potentially fraudulent behavior, payers should constantly update old business information and monitor providers for location changes, employment of unlicensed practitioners, and other potential signs of abuse.
Does the pay and chase system work?
The current pay-and-chase system does not work, and the practices public agencies are adopting must be leveraged in order for the private sector to keep costs under control. “If the whole system, public and private, can be flipped to a preventative model, everybody wins,” said Muckerman.
Everyone Shares the Burden of Health Care Fraud
In 2018, $3.6 trillion was spent on health care in the United States, representing billions health insurance claims. It is an undisputed reality that some of these claims are fraudulent.
What Does Health Care Fraud Look Like?
The majority of health care fraud is committed by a small number of dishonest health care providers, and in some particularly distressing cases, by individuals only posing as legitimate health care providers.
False Patient Diagnoses, Treatment and Medical Histories
Health care fraud, like any fraud, demands that false information be represented as truth. An all too common health care fraud scheme involves perpetrators who exploit patients by entering into their medical records false diagnoses of medical conditions they do not have, or of more severe conditions than they actually do have.
Medical Identity Theft
As a consumer, you are surely aware of the perils of identity theft and the devastating affects it can have on your financial health—jeopardizing bank accounts, credit ratings and your ability to borrow.
Physical Risk to Patients
Shockingly, the perpetrators of some types of health care fraud schemes deliberately and callously place trusting patients at significant risk of injury or even death. It’s distressing to imagine, but there have been many cases where patients have been subjected to unnecessary or dangerous medical procedures simply because of greed.
Health Care Fraud and Organized Criminal Groups
Health care fraud is not just committed by dishonest health care providers.
A Federal Crime with Stiff Penalties
In response to these realities, Congress—through the Health Insurance Portability and Accountability Act of 1996 (HIPAA)—specifically established health care fraud as a federal criminal offense, with the basic crime carrying a federal prison term of up to 10 years in addition to significant financial penalties.
National and State Health Care Fraud Laws
Several laws on the national and state level exist in order to combat health care fraud. These laws keep providers accountable for committing unethical acts within their communities.
How Health Care Providers Can Detect and Prevent Fraud
Health care providers can implement several precautions to help detect and prevent fraud and abuse from taking place.
Seek Guidance from the Industry Leaders in Health Care Law
While most organizations and providers operate ethically, they can unintentionally fail to comply with industry regulations. This leads to criminal and civil investigations that can negatively impact your business’s finances and reputation.
Why This Is A Challenge
- Perpetrators of schemes to defraud Medicare and Medicaid range from criminals who masquerade as bona fide health care providers and suppliers but who do not provide legitimate services or products to Fortune 500 companies that pay kickbacks to physicians in return for referrals. Fraud is a crime of deception, and perpetrators design their schemes to avoid detectio…
Progress in Addressing The Challenge
- Enrollment and Payment.In February 2011, CMS published a final rule implementing the ACA provisions concerning screening of providers and suppliers on the basis of fraud risk. CMS's enhanced payment suspension regulations took effect in March 2011. In this rule and subsequent regulations, CMS established three levels of screening for providers (limited, moderate, and high…
What Needs to Be Done
- CMS has additional opportunities to strengthen the enrollment system, including adopting a more flexible screening approach, tailoring screening measures to fraud risks, and classifying reenrolling durable medical equipment (DME) and home health providers as "high risk" when appropriate. CMS should also focus enrollment scrutiny on providers such a...
Key OIG Resources
- Inspector General Levinson's testimony, Anatomy of a Fraud Bust: From Investigation to Conviction, April 24, 2012
- Exclusion Program information and guidance
- OIG reports on questionable Medicare billing for independent diagnostic testing facility services(OEI-09-09-00380) and comprehensive outpatient rehabilitation facility services (OEI …
- Inspector General Levinson's testimony, Anatomy of a Fraud Bust: From Investigation to Conviction, April 24, 2012
- Exclusion Program information and guidance
- OIG reports on questionable Medicare billing for independent diagnostic testing facility services(OEI-09-09-00380) and comprehensive outpatient rehabilitation facility services (OEI-05-10-00090)
- Program Integrity Problems With Newly Enrolled Medicare Equipment Suppliers (OEI-06-09-00230)
