Who Defines Fraud, Waste, and Abuse?

Transcription

1 Wh Defines Fraud, Waste, and Abuse? This dcument cntains a sample f the varius definitins f the terms Fraud, Waste, and Abuse frm gvernment agencies and health plans. There are mre. The lack f a cncrete definitin in law shuld give pause as cst cntainment initiatives increase. Here are a few questins t cnsider: Wh decides what definitin t use fr these terms? What will the definitins mean fr patient care? What prcedures will be defined as fraud, as waste, as abuse and fr whm? Wh will define thse terms? What will the impact be fr patients caught in the crsshairs between gvernment and health plan cst cutting by definitin and medical treatment decisins? Hw will the 15-member unelected Independent Payment Advisry Bard (IPAB) use these wrds t make decisins abut paying fr care? Hw will the Patient-Centered Outcmes Research Institute (PCORI) evaluate the cmparative effectiveness f varius treatment ptins based n their interpretatins f the terms fraud, waste and abuse? BACKGROUND: Lts f Talk, Little Actin n Medicare Fraud, Gerge LeMieux, The Wall Street Jurnal, Nvember 28, 2012: Examining Optins t Cmbat Health Care Waste, Fraud and Abuse, Energy and Cmmerce Health Subcmmittee, 10:00 a.m. Hearing, 2123 Rayburn, Nvember 28, 2012: Testimny n Fraud Waste and Abuse in Medicare and Medicaid, Daniel R. Levinsn, Inspectr General, U.S. Department f Health and Human Services: ABUSE Abuse An excessive r imprper use f services r actins that are incnsistent with acceptable business r medical practice. This refers t incidents that, althugh nt fraudulent, may directly r indirectly cause financial lss. Examples include: Charging in excess fr services r supplies Prviding medically unnecessary services Billing fr items r services that shuld nt be Humana Cmpliance Plicy, Nvember 2011

2 2 Abuse invlves behavir that is deficient r imprper when cmpared with behavir that a prudent persn wuld cnsider reasnable and necessary business practice given the facts and circumstances. Abuse als includes misuse f authrity r psitin fr persnal financial interests r thse f an immediate r clse family member r business assciate. Abuse des nt necessarily invlve fraud, vilatin f laws, regulatins, r prvisins f a cntract r grant agreement. Department f Defense, OIG Abuse Prviding infrmatin r dcumentatin fr a health care claim in a manner that imprperly uses prgram resurces fr persnal gain r benefit, yet withut sufficient evidence t prve criminal intent. SC BCBS ABUSE (WASTE): Incidents r practices f physicians, ther prviders, service and equipment suppliers, r ther suppliers that are incnsistent with accepted, sund medical, business, r fiscal practices. Examples: A prvider billing fr unnecessary r excessive services. A prvider perfrming labratry tests n large numbers f patients when the prvider knws nly a few tests shuld have been perfrmed. UPMC Health Plan (2009) Fraud, Waste, and Abuse Definitins The Gvernment Accuntability Office s definitins fr waste and abuse are: [ ] Abuse invlves behavir that is deficient r imprper when cmpared with behavir that a prudent persn wuld cnsider reasnable and necessary business practice given the facts and circumstances. Abuse als includes misuse f authrity r psitin fr persnal financial interests r thse f an immediate r clse family member r business assciate. Abuse des nt necessarily invlve fraud, vilatin f laws, regulatins r prvisins f a cntract r grant agreement.... Payment f incentive and award fees in circumstances where the cntractr s perfrmance in terms f cst, schedule and quality utcmes des nt justify the fees is an example f cntracting waste. In cmparisn, an example f cntracting abuse wuld include making prcurement r vendr selectins that are cntrary t existing plicies r unnecessarily extravagant r expensive. It is imprtant fr cntracting prfessinals t be alert t the presence f fraud, waste, and abuse when cnducting their wrk. Defense AT&L, March/April 2009 Abuse - Practices that are incnsistent with sund fiscal, business, r medical practices, and result in an unnecessary cst r reimbursement fr services that are nt medically necessary r that fail t meet prfessinally recgnized standards fr health care. - BCBS f Michigan (Aug 2012) Abuse is defined as practices that are incnsistent with prfessinal standards f care; medical necessity; r sund fiscal, business, r medical practices. Intent is the key distinctin between Fraud and Abuse. An allegatin f waste and abuse can escalate int a fraud investigatin if a pattern f intent is determined. Essence Health Abuse: excessive r imprper use f services r actins that are incnsistent with acceptable business r medical practice. Refers t incidents that, althugh nt fraudulent, may directly r indirectly cause financial lss. Examples include: charging in excess fr services r supplies prviding medically unnecessary services CCHF 161 St. Anthny Avenue, Suite 923 St. Paul, MN P: F: CCHF supprts patient and dctr freedm, medical innvatin and the right f citizens t a cnfidential patient-dctr relatinship.

3 3 billing fr items r services that shuld nt be paid fr by Medicare - FWA presentatin, MN Cuncil f Health Plans, Abuse prviding prducts r services that are incnsistent with accepted practices r are clearly nt reasnable r necessary Example: Billing fr a nn-cvered service-- Delta Dental FWA Training FRAUD SEC DEFINITIONS RELATING TO FEDERAL HEALTH CARE OFFENSE. In General.--Chapter 1 f title 18, United States Cde, is amended by adding at the end the fllwing: ``Sec. 24. Definitins relating t Federal health care ffense ``(a) As used in this title, the term `Federal health care ffense' means a vilatin f, r a criminal cnspiracy t vilate-- ``(1) sectin 669, 1035, 1347, r 1518 f this title; ``(2) sectin 287, 371, 664, 666, 1001, 1027, 1341, 1343, r 1954 f this title, if the vilatin r cnspiracy relates t a health care benefit prgram. ``(b) As used in this title, the term `health care benefit prgram' means any public r private plan r cntract, affecting cmmerce, under which any medical benefit, item, r service is prvided t any individual, and includes any individual r entity wh is prviding a medical benefit, item, r service fr which payment may be made under the plan r cntract.''. (Health Insurance Prtability and Accuntability Act f 1996) Fraud An intentinal act f deceptin, misrepresentatin r cncealment in rder t gain smething f value. Examples include: Billing fr services that were never rendered Billing fr services at a higher rate than is actually justified. Humana Cmpliance Plicy, Nvember 2011 Fraud has been defined in varius ways. Generally Accepted Gvernment Auditing Standards describes fraud as: A type f illegal act invlving the btaining f smething f value thrugh willful misrepresentatin. Whether an act is, in fact, fraud is a determinatin t be made thrugh the judicial r ther adjudicative system and is beynd the auditr s prfessinal respnsibility. Paraphrasing Black s Law Dictinary, fraud is described as: A false representatin f a material fact, whether by wrds r by cnduct, by false r misleading allegatins, r by cncealment f that which shuld have been disclsed, which deceives anther s that he acts, r fails t act t his detriment. Department f Defense, OIG Fraud - Intentinal misuse f infrmatin in rder t persuade anther t part with smething f value r t surrender a legal right. It culd als be an act f planned deceptin r misrepresentatin. SC BCBS Fraud - An intentinal representatin that an individual knws t be false r des nt believe t be true and makes anyway, knwing that the representatin culd result in CCHF 161 St. Anthny Avenue, Suite 923 St. Paul, MN P: F: CCHF supprts patient and dctr freedm, medical innvatin and the right f citizens t a cnfidential patient-dctr relatinship.

4 4 sme unauthrized benefit t him/herself r sme ther persn. BCBS f Michigan (Aug 2012) FRAUD: An intentinal deceptin r misrepresentatin made by a persn, with the knwledge that the deceptin culd result in sme unauthrized benefit t himself/herself r sme ther persn. Examples: A prvider intentinally billing fr services that were nt rendered. Unauthrized use f a member's medical identificatin card r insurance infrmatin. Intentinally inflating medical prcedure cdes t be reimbursed at a higher rate. A member presenting frged r altered prescriptins t pharmacies fr drugs. - UPMC Health Plan (2009) Fraud, Waste, and Abuse Definitins Althugh mst peple have a general understanding f the term fraud, ne f the mst widely quted definitins is fund in Black s Law Dictinary: A false representatin f a material fact, whether by wrds r by cnduct, by false r misleading allegatins, r by cncealment f that which shuld have been disclsed, which deceives anther s that he acts, r fails t act, t his detriment. Defense AT&L, March/April 2009 Fraud is defined as an intentinal deceptin, false statement r misrepresentatin made by a persn with the knwledge that the deceptin culd result in unauthrized benefit t neself r anther persn. It includes any act that cnstitutes fraud under applicable federal r state law. Essence Health Fraud: an intentinal act f deceptin, misrepresentatin r cncealment in rder t gain smething f value. Examples include: billing fr services that were never rendered billing fr services at a higher rate than is actually justified deliberately misrepresenting services, resulting in unnecessary cst t the Medicare prgram, imprper payments t prviders r verpayments - MN Cuncil f Health Plans, Fraud intentinal misrepresentatin f infrmatin fr financial gain. Example: Submitting false claims fr dental services (e.g., filing claims fr services that were nt prvided r fr mre cmplicated services than thse prvided). - Delta Dental FWA Training WASTE Waste Overutilizatin f services (nt caused by criminally negligent actins) and the misuse f resurces. Humana Cmpliance Plicy, Nvember 2011 Waste invlves the taxpayers nt receiving reasnable value fr mney in cnnectin with any gvernment funded activities due t an inapprpriate act r missin by players with cntrl ver r access t gvernment resurces (e.g., executive, judicial r legislative branch emplyees, grantees r ther recipients). Imprtantly, waste ges beynd fraud and abuse and mst waste des nt invlve a vilatin f law. Rather, CCHF 161 St. Anthny Avenue, Suite 923 St. Paul, MN P: F: CCHF supprts patient and dctr freedm, medical innvatin and the right f citizens t a cnfidential patient-dctr relatinship.

5 5 waste relates primarily t mismanagement, inapprpriate actins and inadequate versight. Department f Defense, OIG T use, cnsume, spend r expend thughtlessly r carelessly. SC BCBS Waste - Activities invlving payment r the attempt t btain reimbursement fr items r services where there was n intent t deceive r misrepresent, but the utcme r pr r inefficient billing r treatment methds cause unnecessary csts. - BCBS f Michigan (Aug 2012) Fraud, Waste, and Abuse Definitins The Gvernment Accuntability Office s definitins fr waste and abuse are: Waste invlves the taxpayers nt receiving reasnable value fr mney in cnnectin with any gvernment funded activities due t an inapprpriate act r missin by players with cntrl ver r access t gvernment resurces (e.g. executive, judicial r legislative branch emplyees, grantees r ther recipients). Mst waste des nt invlve a vilatin f law. Rather, waste relates primarily t mismanagement, inapprpriate actins and inadequate versight. Defense AT&L, March/April 2009 Waste is defined as failure t cntrl csts r regulate payments assciated with federal prgram mnies. Essence Health Waste: ver-utilizatin f services (nt caused by criminally negligent actins) and the misuse f resurces - MN Cuncil f Health Plans, Waste extravagant, careless r needless expenditure f healthcare benefits r services that results frm deficient practices r decisins. Example: Over-utilizatin f services r misuse f resurces Delta Dental FWA Training CCHF 161 St. Anthny Avenue, Suite 923 St. Paul, MN P: F: CCHF supprts patient and dctr freedm, medical innvatin and the right f citizens t a cnfidential patient-dctr relatinship.