Necessarily, the first stage in the Medicare fraud investigation process involves the government becoming aware of possible signs of fraud. Federal investigators can uncover what they believe to be fraudulent activity in a variety of ways.
What is the Medicare Coverage Determination process?
Medicare Coverage Determination Process. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).
Does Medicare pay for investigational device exemptions?
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) allowed Medicare payment of the routine costs of care furnished to Medicare beneficiaries in certain categories of Investigational Device Exemption (IDE) studies.
How do I know if my treatment requires approval from Medicare?
Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information. Your provider is responsible for requesting permissions.
Can a Medicaid billing violation result in criminal charges?
State and federal investigations and audits involving provider billing can result in career-ending criminal charges or civil liabilities. If you are a health care professional serving Medicaid patients, here is what you need to know. Medicaid is administered by the states, with federal funding and oversight.
What is a CMS investigation?
CMS of course stands for the Centers for Medicare and Medicaid Services, and thus a CMS investigation is an investigation of health care fraud that involves, at least in part, federal monies such as Medicare, Medicaid and Tricare.
What is considered Medicare abuse?
What Is Medicare Abuse? Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.
Why am I getting calls about Medicare?
Medicare will never call or come to your home uninvited to sell products or services. SSA representatives may call Medicare beneficiaries if they need more information to process applications for Social Security benefits or enrollment in certain Medicare Plans, but, again, this is rare.
Does Medicare ever contact you by phone?
Medicare will never call you! Medicare may need information from you or may need to reach you; but, they'll NEVER call. You'll get a letter that will notify you of the necessary information that Medicare needs. Long story short, if the calls you're receiving claim to be from Medicare, it's a spam call.
What are the three examples Medicare uses to describe abuse?
Common types of abuse include: Billing for unnecessary services (services that are not medically necessary) Overcharging for services or supplies. Misusing billing codes to increase reimbursement.
Does Medicare services call you at home?
Remember that Medicare will never call you to sell you anything or visit you at your home. Medicare, or someone representing Medicare, will only call and ask for personal information in these 2 situations: A Medicare health or drug plan may call you if you're already a member of the plan.
How does Medicare contact?
1-800-MEDICARE You can use Medicare's automated phone system to get information about your Original Medicare claims that were processed in the past 12 months. You don't need to speak to a customer service representative. Just call 1-800-MEDICARE (1-800-633-4227) and provide a few key pieces of information.
How do I block unwanted calls on my landline?
The national Do Not Call list protects landline and wireless phone numbers. You can register your numbers on the national Do Not Call list at no cost by calling 1-888-382-1222 (voice) or 1-866-290-4236 (TTY).
What is an example of abuse in healthcare?
Changing or forging an order or prescription, medical record, or referral form. Selling prescription drugs or supplies obtained under healthcare benefits. Providing false information when applying for benefits or services. Using Transportation Services to do something other than going for medical services.
Which of the following best defines abuse according to the Centers for Medicare and Medicaid Services?
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves paying for items or services when there is no legal entitlement to that payment, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.
What is needed to investigate Medicare fraud?
Investigating Medicare fraud requires knowledge of not only common fraud indicators and schemes, but also the laws that govern them.
How to detect Medicare fraud?
Case management software with case linking capabilities flags files with features in common such as location or subject name. Spot patterns even faster with a trend analysis tool. Using graphs, charts and heat maps, you’ll be able to detect and prevent Medicare fraud schemes more effectively.
What are the Medicare benefits?
Part A of the Medicare program covers hospital and inpatient care for beneficiaries. Part B is medical insurance, covering outpatient medical treatments and supplies as well as preventive services. Common fraud schemes include: 1 Medical identity theft 2 Beneficiaries receiving services they aren’t entitled to 3 Lending or selling Medicare information 4 Billing for services not provided (including missed appointments) 5 Billing for services not covered 6 Unnecessary services 7 Upcoding 8 Unbundling 9 Kickbacks and bribes 10 Paid referrals and conflicts of interest 11 Altered documentation
How much has Medicare recovered from fraud?
Posted by Ann Snook on December 17th, 2019. Since it was first established in 2007, the Medicare Fraud Strike Force has recovered almost $3.82 billion from fraudulent claims and indicted over 3,000 criminals. Unfortunately, fraudsters keep finding new ways to scam the Medicare program, costing taxpayers billions of dollars each year.
How does Medicare fraud affect the taxpayer?
When funds are lost to fraud, Medicare beneficiaries also suffer physically due to reduced access to healthcare.
What is Medicare Part D fraud?
Medicare Part D Fraud. Medicare Part D is an optional add-on that covers prescription drugs. While Part D fraud includes some of the same fraud schemes listed above, investigators may also encounter: Drug diversion (selling or giving the drug to someone it wasn’t prescribed to) Prescription drug abuse.
What is waste in healthcare?
Waste is when someone misuses resources, leading to unnecessary costs to the US government. For example, a doctor could order a lab test that they don’t actually need to diagnose a patient.
What is Medicare coverage?
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).
How long does it take to get a decision on an NCD?
For those NCD requests requiring either an external TA and/or MEDCAC review, and in which a clinical trial is not requested, the decision on the request shall be made not later than 9 months after the date the completed request is received; (§731 (a) (2) (B))
How long is the comment period for CMS?
This comment period shall last 30 days, and comments will be reviewed and a final decision issued not later than 60 days after the conclusion of the comment period. A summary of the public comments received and responses to the comments will continue to be included in the final NCD. (§731 (a) (3) (A))
What is IDE in Medicare?
Instructions: Medicare Coverage Related to Investigational Device Exemption (IDE) Studies. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) allowed Medicare payment of the routine costs of care furnished to Medicare beneficiaries in certain categories of Investigational Device Exemption (IDE) studies.
What is the study protocol for Medicare?
The study protocol must describe how Medicare beneficiaries may be affected by the device under investigation, and how the study results are or are not expected to be generalizable to the Medicare beneficiary population. Generalizability to populations eligible for Medicare due to age, disability, or other eligibility status must be explicitly described.
How to inform CMS of IDE study?
When an IDE study is discontinued after CMS approval, the study sponsor should inform CMS via [email protected] and update the ClinicalTrials.gov web entry consistent with the NIH instructions. Study sponsors should also check the MAC websites for any local requirements.
How long does it take CMS to review a study?
CMS will review each complete submission within approximately thirty days. Study sponsors that have been disapproved may submit revised protocols. Upon request, CMS can meet with study sponsors/applicants for coverage and provide feedback about favorable study protocol adjustments to help improve the likelihood of approval upon resubmission.
When should a study sponsor update ClinicalTrials.gov?
If the study sponsor adds clinical study sites after CMS approval, the study sponsor should update the ClinicalTrials.gov web entry consistent with the NIH instructions.
Do you need to submit a hard copy of a CMS request?
Please note that you do not need to submit both electronic and hard copies of requests to CMS.
Do IDE studies have to be approved by CMS?
IDE studies approved by MACs prior to January 1, 2015 will continue to be administered by the MAC. Study sponsors do not have to submit the protocol to CMS if the participating study investigator sites have already received approval from their MAC. Study sponsors should continue to follow the process established by the MAC for any site additions or protocol changes. Click on this link to find a list of MACs: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors
What is Medicaid provider agreement?
In addition to state statutes authorizing MFCU access to records, Medicaid provider agreements requite providers to furnish to the MFCU any requested records supporting payments for services. As a contracted Medicaid provider, you are under obligation to maintain documentation to support claims for services billed to the Medicaid program. Failure to furnish these records to the MFCU may result in exclusion from federally funded health care programs.
What is Medicaid fraud?
Medicaid provider fraud is a unique focus area of health care fraud prosecutions. Highly specialized law enforcement teams are focused exclusively on carrying out a Medicaid fraud investigation, targeting providers who bill Medicaid for health care products and services.
What happens if you receive a record request?
If you receive a record request, it may be that you are a target of an investigation, or your records are needed for other evidentiary reasons. Many state statutes authorize the MFCU to enter upon the premises of a Medicaid provider and access records and files relevant to the MFCU investigation.
What is the difference between a civil case and a criminal case?
There is one main difference between a criminal case and a civil case. Criminal cases must demonstrate proof of intent to defraud beyond a reasonable doubt. Civil cases, however, require less proof of intent and can be won by demonstrating by a preponderance of the evidence that a provider was merely reckless in the submission of false claims to Medicaid.
What is a false claims lawsuit?
False Claims lawsuits allow the government to recover treble damages and impose civil monetary penalties.
Is MFCU a part of Medicaid?
Each MFCU employs a team of attorneys, investigators and auditors. The MFCU is not a part of the state Medicaid program, and the state program has no authority concerning these prosecutions. In fact, the MFCU has the authority to investigate and prosecute fraud within the administration of the state Medicaid program itself.
Is Medicaid fraud a felony?
Medicaid provider fraud prosecuted at the state level can be a felony or misdemeanor, depending on the state law. In some states, it is a felony regardless of the amount involved. It is important to note that Medicaid fraud cases can be investigated and prosecuted by federal agencies as well. In many instances, such cases involve additional aspects ...
How Do I Get Prior Authorization for Medicare?
Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information.
What services do you need prior authorization for?
The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs.
Does Medicare Advantage cover out of network care?
Unfortunately, if Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full cost to you.
Do you need a Part B prior authorization form?
Although, some meds may require your doctor to submit a Part B Drug Prior Authorization Request Form. Your doctor will provide this form. Once the request gets approval, coverage begins.
Does Medicare require prior authorization?
Medicare Part A Prior Authorization. Medicare, including Part A, rarely requires prior authorization. If it does, you can obtain the forms to send to Medicare from your hospital or doctor. The list mostly includes durable hospital equipment and prosthetics.
Does Medicare cover MRI?
If the purpose of the MRI is to treat a medical issue, and all providers involved accept Medicare assignment, Part B would cover the inpatient procedure. An Advantage beneficiary might need prior authorization to visit a specialist such as a radiologist.
The OIG Investigation Process
The OIG is responsible for investigating a wide range of civil and criminal healthcare fraud matters. While the OIG investigation process varies slightly depending on the allegations and how they are discovered, an investigation typically takes the following path:
Surviving an OIG Audit
The thought of an OIG audit is overwhelming to many healthcare providers. And for good reason, OIG audits are not only incredibly burdensome and invasive but also present very high stakes. Thus, providers must understand what they can do to protect themselves in advance of an audit as well as how to effectively respond if they are audited.
What is the next step in an investigation?
The next step is the full investigation, which will include the collection of all facts pertaining to the incident and the drafting of a conclusion, which should also state what can be done to prevent further occurrences. This investigation must focus only on the facts, because starting out by seeking who to blame often diverts attention away from what actually took place.
What should an investigator look for in a medical record?
The investigator should be on the lookout for any notes in the resident’s medical record relevant to the time frame of the event, which might have bearing on the facts of the situation . These could include, for example, any change in the resident’s mood, demeanor, and function before and after the incident. Such changes can, depending upon the nature of the incident, be a good indicator of the accuracy of the allegations. If it appears that a crime has been committed, then local police must be informed at once, and all evidence secured and protected for their investigation.
What is the duty of an investigator to report abuse?
If, during any investigation, the facts point to possible abuse, then it is the investigator’s duty to immediately report this to the relevant authorities who must implement a full abuse investigation protocol.
What are the procedures for a long term care facility?
All long-term care facilities which accept Medicare/Medicaid funding are obligated to have written procedures for investigating resident abuse, neglect, misappropriation, and exploitation. These procedures must contain a list of clearly defined personnel who are responsible for conducting the investigation, and who have training in ensuring that all evidence is collected and analyzed. Furthermore, these personnel should have training in the handling of evidence, particularly in cases where it appears a crime has been committed. This is necessary in order to preserve all evidence from destruction or tampering.
Who must be interviewed in a criminal investigation?
The investigators must identify and interview all involved persons, including the resident/alleged victim; the alleged perpetrator or perpetrators, if known; any witnesses; and all others who might have knowledge of the incident or allegations.
