Health Care Fraud for Physicians UNM Family Medicine Residency Program May 25, 2011
Or... Why I Should Have Never Become A Doctor In The First Place
Fraud Fraud vs. Abuse Intentional deception or misrepresentation made with knowledge that the deception could result in an unauthorized benefit to self or others. Abuse Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to a health insurance program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
Who commits health care fraud?
Billing Practices Providers Services not rendered Equipment or supplies not provided Misrepresentation of services Upcoding Unbundling Duplicate claims Double billing Altered claims to receive higher payment Unnecessary or excessive services Misrepresenting condition or diagnosis to justify services provided Services not meeting professionally recognized standards Excessive charges for services or supplies Intra-referral pattern
Providers Kickbacks, Bribes, Rebates Soliciting, Offering, Receiving Money, Services, Items
Patients Identity Theft Doctor Shopping Drug Diversion
Employees Billing Practices Payment Diversion
Outsiders Identity Theft Phantom Billing Kickbacks, Bribery Albuquerque Journal, Thursday, October 14, 2010 7 Foreigners Charged With Medicare Fraud
Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule Regulates use and disclosure of information held by covered entities Protected health information (PHI) individually identifiable health information Identifies the individual, including demographic data Health status Provision of health care Payment for health care
Health Insurance Portability and Accountability Act (HIPAA) Required disclosures (must disclose) Individual or personal representative Request for PHI Disclosure accounting HHS if compliance investigation or review, or enforcement action Permitted use and disclosure (without authorization) Individual Treatment, payment, health care operations Opportunity to agree or object Public interest and benefit activities Law enforcement purposes
Health Insurance Portability and Accountability Act (HIPAA) Authorized use and disclosure Written authorization required Minimum necessary PHI Restrict access and use of PHI Privacy Practices Notice
Stark Law Physician self-referral Medicare and Medicaid patients Financial interest (doctor or immediate family member) Ownership Investment Structured compensation arrangement Designated health services Clinical laboratory services Physical/occupational therapy services Radiology services Radiation therapy services and supplies Durable medical equipment and supplies Parenteral and enteral nutrients, equipment, and supplies Prosthetics, orthotics, and prosthetic devices and supplies Home health services Outpatient prescription drugs Inpatient and outpatient hospital services Exceptions to provisions exist
Criminal Penalties Health care fraud Up to 10 years imprisonment $250,000 fine (per count) False statements Up to 5 years imprisonment $250,000 fine (per count) HIPAA violation $50,000 fine and up to 1 year imprisonment $100,000 fine and up to 5 years imprisonment if false pretenses involved $250,000 fine and up to 10 years imprisonment if intent to sell, transfer, or use for commercial advantage, personal gain, or malicious harm
Civil False Claims Act Penalties 3 times amount of payment received $5,500-$11,000 penalty per claim HIPAA violation $100 per failure, up to $25,000 per year (multiple violations) Stark Law violation $15,000 per service $100,000 per arrangement if considered circumvention scheme
Patients Protect yourself Verify identity of patient Inquiry Employees Oversight Random checks Outsiders Protect your medical identification information Beware of something that seems too good to be true Doctors Documentation Don t do it
Reporting fraud Medicare Department of Health & Human Services Office of the Inspector General Medicaid Fraud Control Unit Tricare Defense Criminal Investigative Service Private Insurance Corporate Hotline or SIU FBI
Questions? Jennifer Keppler Special Agent FBI Albuquerque Division 4200 Luecking Park Ave. NE Albuquerque, NM 87107 (505) 889-1545 Jennifer.Keppler@ic.fbi.gov