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Medicare defines
Medicare Fraud as "an intentional deception or misrepresentation
that the individual knows to be false or does not
believe to be true, and makes knowing that the deception could
result in some unauthorized benefit to himself/herself or some
other person. The
most frequent kind of fraud arises from a false statement made,
or caused to be made, that is material to entitlement to
the Medicare program. The violator may be a participating provider, a
beneficiary, or some other person or business entity."
Some general
examples of fraud that various Medicare providers have committed include:
- Billing
for services not provided,
- Billing
for unqualified Medicare beneficiaries,
- Forging/altering
physician signatures, orders and/or dates,
- Billing
incorrect diagnoses, procedures or service codes to maximize reimbursement,
- Misrepresentations
(altering documentation/medical records) of dates, descriptions of services
furnished, or identification of the person receiving the services or
the individual who furnished the services in order to receive or maximize
reimbursement,
- Billing
for services that are not medically reasonable and necessary per Medicare
guidelines,
- Reporting
of non-Medicare related expenses on the Medicare cost report, (personal
expenses/salaries to family or friends for fictitious jobs),
- Reporting
of expenses on the Medicare cost report that were never incurred, (phantom
vendor/fabricated invoices), and
- Providing
or receiving kickbacks.
Together with CMS, providers can help identify and prevent fraud and abuse; the first step for providers to protect themselves is to understand the legal definitions and be able to identify fraudulent and abusive practices. The Medicare Fraud & Abuse fact sheet from Medicare Learning Network (MLN) provides information on many available resources to help you understand what to do if you suspect or become aware of incidents of potential Medicare fraud or abuse:
http://www.cms.hhs.gov/MLNProducts/downloads/Fraud_and_Abuse.pdf
Actions
Providers Can Take to Prevent Medicare Fraud
In addition
to education and staying informed about Medicare current billing and coverage
issues, providers can take other actions to protect themselves against
Medicare fraud. While TrustSolutions does not develop or critique corporate
compliance programs for the provider community, we do support the concept
of corporate compliance programs as an effective measure in preventing
fraud and abuse.
The Office
of Inspector General (OIG) has on their Internet web site a number of
compliance program guidance for specific provider types. In addition to
this resource, they also have posted Safe Harbor regulation information,
advisory opinions, fraud alerts, bulletins, open letters to providers,
and the OIG exclusion list. The OIG web site can be accessed at www.oig.hhs.gov.
Lastly, TrustSolutions
developed the following Fraud Prevention Checklist for Medicare providers
which identifies other actions providers can take to help prevent your
agency/business from being involved in Medicare fraud. |
