A Day In The Life Of A Healthcare Fraud Investigator

Transcription

1 A Day In The Life Of A Healthcare Fraud Investigator MY VIEW FROM THE TRENCHES Maria Seedorff, DC AHFI CPC Dr. Seedorff is a Clinical Special Investigator with Healthcare Fraud Shield s Special Investigations Unit (SIU). In this role, she performs detailed clinical and data reviews on a wide variety of issues and schemes. Maria has been involved in healthcare for over 25 years, including ten years in healthcare fraud, waste and abuse investigations. She previously managed the Special Investigations Unit at a Blues Plan. She holds a Bachelor s degree in Accounting, a Doctor of Chiropractic, is an Accredited Health Care Fraud Investigator (AHFI) with the National Health Care Anti-Fraud Association (NHCAA) and a Certified Professional Coder (CPC). 1

2 Disclaimer The ideas and opinions expressed during this presentation are those of the presenter and do not represent official policy or position of Healthcare Fraud Shield or of its clients. Overview Review the Fraud, Waste and Abuse investigation process Share common schemes and cases Discuss federal laws related to healthcare fraud Outline CPC s role in FWA investigations, recommended skills and experience 2

3 FRAUD, WASTE and ABUSE (FWA) Fraud Fraud is a specific offense with defined components: o There is a false statement or a material misrepresentation. o There is knowledge that the statement is false or misleading. o There is intentto deceive the victim. o There is relianceby the victim on the false statement. o The action results in benefitsto which the individual or entity is not entitled. All components must be present to prove an allegation of fraud. 3

4 Waste and Abuse Waste is defined as a loss through carelessness, inefficiency, or ignorance. Example: When apharmacy automatically refills 30 day prescriptions every 28 days, resulting in 13 monthly prescriptions in a year. Abuseisconsidered an action that is not consistent with generally accepted standards and practices of the industry. Example: A pattern of waiving cost-shares or deductibles. FWA Statistics The National Health Care Anti-Fraud Association estimates (conservatively) that health care fraud costs the United States about annually? A. $68,000,000 B. $680,000,000 C. $6,800,000,000 D. $68,000,000,000 4

5 FWA Statistics The National Health Care Anti-Fraud Association estimates that health care fraud costs the United States about $68,000,000,000 annually, or about 3% of the nation s $2.26 trillion in health care spending. Other estimates range as high as 10% of annual health care spending, $230 billion lost to fraud annually. By comparison, in FY 2013 Federal health care fraud prevention and enforcement efforts recovered $4.3 billion in taxpayer dollars. Who Do Investigators Investigate? Physicians Dentists Mental Health Providers Physical Therapists Podiatrists Ambulance Companies Chiropractors Hospitals Labs DME Suppliers Members Pharmacies Home Health Agencies 5

6 Common Fraud Schemes Billing for services not rendered Upcoding Double billing Unbundling Misrepresentation of services Unnecessary services/dme Billing for family members Sharing insurance card Falsifying diagnosis Kickbacks Pharmacy Fraud Billing for free services Phantom providers Unlicensed providers Overcharging or waiving patient financial responsibility Billing for Services Not Rendered Definition: Billing for services that were never rendered, including services that are not documented in the record. Examples: Member has authorization for eight speech therapy visits, attends four of them, but the provider bills the health plan for all eight. A provider bills for an office visit and an immunization, whenthemember only received an immunization. 6

7 Upcoding Definition: Billing for a more complex code that does not accurately reflect the services rendered, resulting in a higher rate of reimbursement. Examples: Billing for a higher level E&M service than is supported by the levels of history, exam and medical decision-making actually performed. Billing for a larger size lesion removal than was performed. Unbundling Definition: Billing for component procedures in addition to a primary or global code. Examples: Surgeon bills separately for abdominal diagnostic laparoscopy, laparoscopic appendectomy and lysis of adhesions, when the three procedures are included in Laparoscopy, surgical, appendectomy. Billingseparatelyforservices included in maternity global packages 59400/ (Including initial and subsequent visits, routine urinalysis, delivery of baby, post-op visits, etc.) 7

8 Misrepresentation of Services Definition: Billing for one service when a different service is performed. Usually the service performed is not a covered benefit. Examples: Billing for individual psychotherapy when group therapy is the service performed. Billing for sinus surgery when the patient actually had a rhinoplasty. Medically Unnecessary Services Definition: Performing and billing for medical services that are covered for third party reimbursement, however, are not needed to threat the patient. Examples: Performing a dental crown when a filling would address the condition. Utilizingstandardlabpanels, that are not specific to each patient s condition. (Seen in drug testing for opioid/pain management.) 8

9 Prescription Fraud Member Examples: Calling prescriptions to a pharmacy, pretending to be a doctor or employee of the doctor s office. Stealing prescription pad from a doctor s office. Diverting prescriptions for sale on the street. Prescription Fraud Provider Examples: Prescribing controlled substances for return of favors. Prescribing certain brands in anticipation of a drug company kickback. Operating a pill mill. 9

10 INVESTIGATING HEALTHCARE FWA Three Phases of FWA Investigation Identification Phase Investigation Phase Resolution Phase 10

11 Identification Phase: Referral Sources Complaints/Referrals Fraud Hotline calls/ s TV/Radio/Social Media Advertisements Proactive data mining Fraud Detection Software Special Investigation Resource and Intelligence System (SIRIS) Database State Licensing Boards OIG Work Plan Identification Phase: Validating the Tip Review utilization of codes (for a provider, a group, a specialty, a code, etc.): o Do billed codes align with stated provider specialty? o Have there been changes in coding, billed amount(s) and/or reimbursement? o Does billing exceed reasonable work days? o Is provider an outlier when compared with peers? Internet and Social Media review: o Verify license, specialty and sub-specialties. o Review website/facebook for services offered. Determine any previous tips/complaints for the same provider or issue. 11

12 Investigation Phase: Medical Records The provider is notified of the audit and medical records are requested. Selection of claims for medical record requests (sampling) can be: o Patient-specific: All records are requested for selected patients. o Scheme or code-specific: Records are selected for specific dates or codes. o Based on Statistical Random Sampling Software: RAT-STATS (DHHS OIG) Investigation Phase: Medical Records Medical records are reviewed for: o CPT, HCPCS and ICD coding verification. o Validate provider of record vs billing provider. o Compare documented services vs medical policy. o Determine: (1) Do medical records support the billed services? (2) Do claims/medical records reflect the reported complaint? 12

13 Investigation Phase: More Verification Member calls or letters for verification of services received. Onsite visit to provider location (scheduled or unscheduled). Additional medical record requests and/or onsite review of records Records reviewed by third-party/peer reviewer. Decision -> Does research support the reported complaint? -> Does research reveal any other/additional concerns? -> Is the reported complaint unfounded? Resolution Phase: Audit Completion If Fraud, Waste or Abuse issue(s) are identified: o Provider Education Letter or Education with Recoupment of Overpayment. o Actual overpayment vs. Extrapolation. o Expectation of change in provider billing behavior. o Pre-Pay or Claim Hold Edit. o Terminate network participation. o Report to State Licensing Authority. o Report to Law Enforcement (OIG, FBI), based on type of plan. Anticipate provider appeal! 13

14 LAWS Health Insurance Portability and Accountability Act of 1996 (HIPAA) HIPAA is a Federal Law affecting the healthcare industry. HIPAA protects the privacy and security of a patient s health information. HIPAA simplifies billing and other transactions, reducing health care administrative costs. HIPAA is mandatory. HIPAA prevents healthcare fraud and abuse. 14

15 Health Insurance Portability and Accountability Act of 1996 (HIPAA) Title II Preventing Health Care Fraud and Abuse, Administrative Simplification, and Medical Liability Reform. The Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) is responsible for investigating those who commit Medicare fraud; and for presenting case(s) for criminal or civil prosecution. Civil False Claim Act Any person who (1) knowingly presents, or causes to be presented a false or fraudulent claim for payment or approval; (2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; (3) conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government;... or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to the Government Isliableforacivil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages (Per Claim Line) CMS 15

16 Whistleblower Provision An important provision in the False Claims Act protects individuals who act as whistleblowers. Whistleblower may include: An employee, former employee, member of an organization, or any person who reports misconduct to people or entities that have the power to take corrective action. Whistleblowers are protected against retaliation if they report misconduct in good faith. Whistleblower Provision Under the False Claims Act, individuals who have knowledge of fraud or misconduct in government programs may: Report fraud anonymously Sue an organization for submitting false claims on behalf of the government, and collect a portion of any settlement that may result Employers cannot threaten or retaliate against whistleblowers. 16

17 Anti-Kickback Statute Prohibits: Soliciting, receiving, offering or paying any kickback, bribe or rebate in return for referrals for (or the purchasing, ordering, arranging or recommendation of) services that are paid in whole or in part under a federal health care program (which includes the Medicare program). Penalty: Any person who knowingly accepts such remuneration will be fined up to $25,000, imprisoned up to 5 years, or both. Significant civil monetary penalties may also apply. Further, conviction results in mandatory exclusion from participation in federal health programs. Stark Statute: Physician Self Referral Law Prohibits: A physician from making a referral for certain designated health services payable by Medicare to an entity in which the physician (or member of his or her immediate family) has a financial relationship (ownership, investment interest or compensation arrangement), unless an exception applies. Also prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity or third party payer) for those referred services. 17

18 Stark Statute: Physician Self Referral Law Penalty: Any individual/entity who knowingly participates in a prohibited referral arrangement may be fined, among other amounts and penalties: Up to $15,000 fine for each fraudulent claim Up to $100,000 fine for entering into an arrangement or scheme Consequences of Committing FWA Potential penalties: Civil Prosecution/Monetary Penalties Criminal Conviction/Fines Imprisonment Loss of Professional License Exclusion from Federal Health Care Programs 18

19 Civil Monetary Penalties (CMPs) The Civil Monetary Penalties Law authorizes the imposition of CMPs for a variety of health care fraud violations. Different amounts of penalties and assessments may be authorized based on the type of violation. Penalties range from $10,000 to $50,000 per violation. CMPs also may include an assessmentofuptothreetimestheamountclaimedforeachitemor service oruptothreetimestheamountof remuneration offered, paid, solicited or received. Exclusion from Participation in Federal Health Care Programs What causes individuals or entities to be excluded? Mandatory Exclusion for conviction of (for example): o Medicare/Medicaid/SCHIP/State health program fraud or other offense o Patient abuse or neglect o Unlawful activity related to controlled substances. Permissive Exclusion at the OIG s discretion for (for example): o Misdemeanor convictions of the same issues o Submission of false claims and/or engaging in kickbacks o Defaulting on health education loan or scholarships obligation(s). 19

20 Exclusion from Participation in Federal Health Care Programs No Federal health care program payment may be made for any items or services: (1) Furnished by an excluded individual or entity, or (2) Directed or prescribed by an excluded physician. This applies to Federal health care programs: Medicare/Medicaid State Children s Health Insurance Program TRICARE Federal Employee Health Benefit Plan Indian Health Services Veterans Health Administration Exclusion from Participation in Federal Health Care Programs Examples of items or services that violate the exclusion law, when reimbursed directly or indirectly by a Federal health care program: Services performed by excluded nurses, technicians or other excluded individuals who work for a hospital, nursing home, home health agency or physician practice; Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing; Services performed by excluded ambulance drivers, dispatchers and other employees involved in providing transportation; Services performed by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer. 20

21 Exclusion from Participation in Federal Health Care Programs Penalty for OIG Exclusion Violation: Civil Monetary Penalty of $10,000 for each item or service furnished during the period that the person or entity was excluded. Individual or entity may also be subject to triple damages for the amount claimed(not the amount reimbursed) for each item or service. Exclusion violation may jeopardize future reinstatement into Federal health care programs. Exclusion from Participation in Federal Health Care Programs Determine if an Individual or Entity is Excluded: Health care providers and entities should check the OIG List of Excluded Individuals/Entities (LEIE) database prior to hiring or contracting with individuals or entities; Health care providers should periodically check the OIG List of Excluded Individuals/Entities (LEIE) database to determine the participation/exclusion status of current employees and contractors

22 THE CPC FRAUD INVESTIGATOR CPC Role in FWA Investigations Certified Professional Coders (CPCs) are invaluable in FWA investigations. Many common healthcare FWA schemes are coding-based, and rely on CPCs to: Perform detailed medical record reviews. Identify aberrant documentation or billing patterns. Provide written feedback summarizing identified deficiencies. Many third-party and government payers require CPC coding certification as a minimum requirement for FWA investigators. 22

23 Valuable CPC Skills and Experience Coding experience across varied specialties and provider types. Intermediate or higher Excel competency. Excellent report-writing skills. Ability to communicate complex billing schemes to a non-coder audience. Experience interpreting and applying medical policies. Background in third party payer and/or claim processing environment. Demonstrated experience researching documentation/coding/billing issues. Ability to identify and report financial impact of billing schemes. Don t Be A Victim of Healthcare Fraud o Protect your health insurance ID card as if it were a credit card. o Don t share your policy number with telephone solicitors or over the Internet. o Review you explanations of benefits; verify the services billed were actually received. o Beware of free offers (If it s too good to be true it probably is). o Contact your insurance company with any concerns. 23

24 QUESTIONS? Maria Seedorff, DC AHFI CPC Clinical Special Investigator Healthcare Fraud Shield (816)