UPICs promote the integrity of Medicare through benefit integrity (fraud and abuse) functions. They help address fraud, waste and abuse by performing regional Medicare data analysis as well as comprehensive problem identification and research to identify potentially fraudulent Medicare providers.
Who is responsible for investigating Medicare fraud and abuse?
Zone Program Integrity Contractor (the Medicare contractors responsible for investigating potential fraud and abuse) and formally referred as part of a case by one of the contractors to the Office of Inspector General for further investigation.
What is in the Medicare fraud and abuse booklet?
This booklet provides the following tools to help protect the Medicare Program, your patients, and yourself: ● Medicare fraud and abuse examples ● Overview of fraud and abuse laws ● Government agencies and partnerships dedicated to preventing, detecting, and fighting fraud and abuse ● Resources for reporting suspected fraud and abuse
What is the purpose of the health care fraud and abuse program?
The overall goal of the Health Care Fraud and Abuse Program is to further enable the identification, investigation and, where appropriate, prosecution of those individuals and entities who commit fraud against the nation's health care delivery system.
What is the difference between Medicare fraud and 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. The difference between “fraud” and “abuse” depends on specific facts, circumstances, intent,
What is the Medicare Integrity Program?
The Medicare Integrity Program (MIP) provides funds to the Centers for Medicare & Medicaid Services (CMS--the agency that administers Medicare--to safeguard over $300 billion in program payments made on behalf of its beneficiaries.
What agency fights Medicare fraud?
the Office of the Inspector GeneralHave your Medicare card or Medicare Number and the claim or MSN ready. Contacting the Office of the Inspector General. Visit tips.oig.hhs.gov or call 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950.
Which is the most common form of health care fraud and abuse?
Fraudulent provider billing, duplicate billing, and billing for services not medically needed accounted for 46 percent of provider fraud cases in 2016. Billing for services not performed is the most common provider fraud activity and defrauds millions from public and commercial insurers alike.
What are the major types of healthcare fraud and abuse?
Some of the most common types of fraud and abuse are misrepresentation of services with incorrect Current Procedural Terminology (CPT) codes; billing for services not rendered; altering claim forms for higher payments; falsification of information in medical record documents, such as International Classification of ...
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 do you fight Medicare fraud?
If you suspect Medicare fraud, do any of these: Call the fraud hotline of the Department of Health and Human Services Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950. Visit tips.oig.hhs.gov to file a complaint online.
Why is Medicare fraud an issue?
There are health care consequences due to Medicare fraud. A beneficiary may later receive improper medical treatment from legitimate providers because of inaccurate medical records that may contain false diagnoses or incorrect lab results.
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 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 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.
Is CPT copyrighted?
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability of data contained or not contained herein.
What is the goal of the Health Care Fraud and Abuse Program?
The overall goal of the Health Care Fraud and Abuse Program is to further enable the identification, investigation and, where appropriate, prosecution of those individuals and entities who commit fraud against the nation's health care delivery system.
What is Medicaid fraud control unit?
State and Local Audits: As noted above, almost all states have Medicaid Fraud Control Units (MFCUs) which are responsible for the investigation and prosecution (or referral for prosecution) of all criminal violations of state laws regarding fraud on the Medicaid program.
What is the Department of Health and Human Services Office of Inspector General?
The Department of Health and Human Services Office of Inspector General (HHS-OIG) focuses primarily on fraud on the Medicare and Medicaid programs and the health benefits programs of the United States Public Health Service (PHS) such as the Indian Health Service.
What is the HHS OIG?
Prior to the passage of the Health Insurance Portability and Accountability Act of 1996, the HHS-OIG offered advice to the public with respect to the Medicare and Medicaid Anti-Kickback statute, 42 U.S.C. 1320a-7b (b), in the form of "safe harbor" regulations and Special Fraud Alerts.
What is the purpose of the Department of Justice and Health and Human Services?
Annually the Department of Justice and the Department of Health and Human Services will assess the effectiveness of the Program in combatting health care fraud and abuse. This assessment will include factors such as the appropriateness of the program's goals and objectives, the performance of the organizations which receive funds from the Account, and possible new areas to direct resources.
How can a health care fraud task force help?
Task Forces and Working Groups: Federal, State, local, or regional health care fraud task forces/working groups can improve health care fraud enforcement by encouraging communication and coordination among law enforcement officials in the use of criminal, civil, and/or administrative remedies.
How is health care fraud and abuse control promoted?
Health care fraud and abuse control is promoted when Federal, State, and local law enforcement entities share information about trends in health care fraud, emerging investigative and prosecutorial techniques, and other information necessary to achieve the common goal of controlling health care fraud.
What is Medicare abuse?
Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. You do not play a vital role in protecting the integrity of the Medicare and to prevent fraud and abuse.
How can gravity help with fraud?
You can help prevent Fraud, Waste, and Abuse (FA) by doing all of the following: Look for suspicious activity; Conduct yourself in an ethical manner; Ensure accurate and timely data/billing; Ensure you coordinate with other payers; Keep up to date with FA policies and procedures, standards of conduct, laws, regulations, ...
What is the criminal health care fraud statute?
Section 1347) prohibits knowingly and willfully executing, or attempting to execute, a scheme or lie about the delivery of, or payment for, health care benefits, items, or services to either : . }Defraud any health care benefit program.
How to report fraud and abuse?
You can report suspected fraud & abuse anonymously by phone (OIG Hotline), email, fax, mail, and on the OIG website.
What is Medicare Learning Network?
The Medicare Learning Network® (MLN) offers free educational materials for health care professionals on Centers for Medicare & Medicaid Services (CMS) programs, policies, and initiatives. Get quick access to the information you need.
What are some examples of fraud?
Examples of fraud cases include: A hospital paid $8 million to settle allegations it knowingly kept patients hospitalized, beyond the time considered medically necessary, to increase its Medicare payments and maintain its classification as a long-term acute care facility. FRAUD EXAMPLE 1: FRAUD EXAMPLE 2 :
How long was a home health provider sentenced to prison?
A court sentenced a home health provider to 168 months in prison for his role as one of the owners of a home health agency that submitted about $45 million in false claims to Medicare. Almost all his insulin claims billed twice-daily injections to purportedly homebound diabetic patients.
What is a CMP in civil law?
A CMP for each item or service in non-compliance (or higher amounts where applicable by statute) Civil Prosecutions and Penalties -Example 2. Payment up to 3 times the amount claimed for each item or service instead of damagessustainedby the Federal government. Civil Prosecutions and Penalties -Example 3.
Statement of Program Goals
- The overall goal of the Health Care Fraud and Abuse Program is to further enable the identification, investigation and, where appropriate, prosecution of those individuals and entities who commit fraud against the nation's health care delivery system. Also, the Program is to alert the public, service providers, industry groups, and consumers to suc...
Funding
- Control Account funds are provided by the Act to cover costs (including equipment, salaries and benefits, and travel and training) of the administration and operation of the Program, including the costs of: 1. prosecuting health care matters (through criminal, civil, and administrative proceedings); 2. investigations; 3. financial and performance audits of health care programs an…
Evaluation
- Annually the Department of Justice and the Department of Health and Human Services will assess the effectiveness of the Program in combatting health care fraud and abuse. This assessment will include factors such as the appropriateness of the program's goals and objectives, the performance of the organizations which receive funds from the Account, and pos…
Revisions
- This Program statement and accompanying Guidelines may be modified, as appropriate, upon agreement of the Attorney General and the Secretary. NOTE: Neither the Health Care Fraud and Abuse Control Program nor these guidelines create any rights, privileges or benefits, either substantive or procedural, enforceable at law by any person in any administrative, civil or crimin…
Definitions
- The following acronyms and definitions are used herein: 1. "AG" shall mean the Attorney General of the United States. 2. "AOA" shall mean the United States Administration on Aging within the Department of Health and Human Services 3. "CHAMPUS" shall mean the Civilian Health and Medical Program of the Uniformed Services. 4. "DCAA" shall mean the Defense Contract Audit A…
VI. Coordination and Exchange of Information
- In order to facilitate the enforcement of civil, criminal, and administrative statutes relating to fraud and abuse with respect to health plans, the following guidelines are provided to facilitate the exchange of information under the Program: 1. Guidelines for Exchange of Information 1.1. Health Plan Exchange of Information with Law Enforcement and Other Health Plans Each health plan s…