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Unrestricted National Medicare Fraud Alert Essay, Research Paper

Unrestricted National Medicare Fraud Alert (UMFA 9802, issued June 9, 1998) REVISED October 6, 1998(Revisions are Shown in Italics): Billing for Services Not Rendered or Not Medically Necessary; Upcoding (Billing for Powered Wheelchairs and Delivering Power Operated Vehicles (POVs)); and Exchanging Power Wheelchairs for POVs After the Wheelchairs Were Paid.

DME companies are utilizing three mechanisms to obtain inappropriate reimbursement for power vehicles, primarily for beneficiaries in Florida. The three mechanisms are:

1. They (the DME companies) bill for services not rendered or not medically necessary; or

2. They deliver a POV (scooter) and bill for a power wheelchair; or

3. They deliver and bill for a power wheelchair, and after receiving payment go back to the beneficiary and exchange it for a POV.

The primary AK@ codes appearing were – K0011, K0021, K0031, K0034, K0067, K0073, K0081, and K0086. All these codes appeared in the beneficiaries= EOMBs. Codes E0192, E1399, and L0700 were billed in different combinations with the above AK@ cod

Source: www.hcfa.gov/medicare/fraud/9802A.HTM

These companies were submitting a large number of claims for CPT Code 93268 – transtelephonic arrhythmia monitoring test and for the following range of codes from 93270 – 93272, 93012-93014 and codes G0004-G0016.

When 93268 is billed, 93270, 93271 and/or 93272 should not be billed.

These companies were also under investigation for submitting fraudulent claims for surgical dressings and incontinence supplies.

Contractors should look for the following:

? Claims for numerous beneficiaries residing at the same address.

? “Impossible date of service scenarios” such as a provider rendering volumes of services which seem potentially impossible.

? Doctors who work for the suppliers and beneficiaries that reside outside of the carrier jurisdiction.

? Doctors who make no other appearance in the beneficiaries histories other than being the ordering physicians on the IPL’s claims.

? Multiple carriers paying for the same beneficiaries.

Source: www.hcfa.gov/medicare/fraud/9704A.HTM

Listing of Medicare Fraud Alerts

The Health Care Financing Administration (HCFA) issues a fraud alert when it has identified an apparent Medicare scam or fraudulent scheme, which is operating in multiple States. Alerts are appropriate if the scheme represents a potentially significant loss in dollars to Medicare or poses a threat to patient health or safety. HCFA issues alerts to all Medicare fraud units, federal and selected State law enforcement agencies, and as appropriate, provider and beneficiary groups. The purpose of the alerts is to enable Medicare, its providers, and its program beneficiaries to protect themselves from fraudulent schemes.

There are two classifications for fraud alerts, Unrestricted and Restricted. The unrestricted alerts furnish detailed information on the scheme but they do not identify specific providers thought to be involved in the operation of the scheme. Restricted alerts describe the scheme and specify suspected providers and entities. Because the names of providers under investigation are not disclosable, we delete all provider-identifying information from the text of the alert.

Source: www.hcfa.gov/medicare/fraud/UMFA2.HTM

Health Care Financing Administration

National Fraud, Waste and Abuse Conference

March 17, 1998

Summary of Major Themes*

Disclaimer: The statements included in the following conference proceedings are from a variety of sources and are not necessarily endorsed by the Health Care Financing Administration. Futhermore, the transcript portion of the proceedings has not been edited.

Best Practices


? Improve provider enrollment processes:

o use site visits to verify provider addresses

o in person application process

o provider application forms should be consistent across the country, and should be developed in consultation with U.S. Attorney=s office to insure that false statements on application forms can be prosecuted

o require providers to periodically report on employees and financial backers

o utilize credentialing as a gatekeeper to the program

o follow new providers for a certain period of time–watch their billing patterns

? Promote education:

o beneficiaries need to be educated about program and fraud issues; find best vehicles in each community (for example, area units on aging, advocacy groups, clergy, etc.)

o target particularly vulnerable beneficiary populations, such as immigrant groups

o Explanation of Medicare Benefits (EOMBs) need to be sent out in a more timely fashion

o all Medicaid beneficiaries should receive EOMB type statements and be encouraged to review for inconsistencies with care provision

o more provider education, including better communication of policies

o help beneficiaries understand that addressing fraud should not reduce access to legitimate medical services

? Encourage and support development of corporate compliance programs:

o more consistent guidance and interpretation from HCFA and oversight groups about proper practices (for example, documentation)

? Promote administrative simplification:

o make Medicare and Medicaid rules easier for beneficiaries and providers to understand

o make it easier for beneficiaries to asked questions, report fraud

? Zero tolerance policy for fraud:

o a zero tolerance message needs to be enforced and emphasized throughout the provider community as well as government.

? Change contractor incentives:

o historically, contractors primary incentives were to pay claims quickly and efficiently. Change incentives to encourage and support fraud and abuse detection.

? Encourage a ‘fear’ of prosecution and punishment for unscrupulous providers:

o publicize the punishments to achieve a sentinel effect

o need to create a fear of being detected; random on site aggressive reviews.

o well focused random reviews and audits.

o unannounced auditor visits

? Eliminate provider fear and foster ability for honest providers to do what’s right:

o educational review; Aforgive@ past transgressions — declare past transgressions Aoff the table@ and let organizations look forward

o engage providers in policing their own

? Initiate Administrative Law Judge (ALJ) reform:

o change regulations to reduce improper reversals


Foster beneficiary involvement:

- help beneficiaries to keep track of the services they receive by requiring physicians to provide a detailed receipt at the time of service (Aimmunization record@ concept)

Develop individual, unique provider number:

- critical in order to detect multiple billing

Develop and use software:

- needs to be improvements to catch aberrancies — look for large increases in expenditures and volume over short periods of time or in small geographic areas; uniform data an software to address scams and abusive actions in Areal time@ and across geographic and service areas

- Use more computer edits: Medicaid experience is that Medicaid is getting taken for things that simple edits would have prevented

Develop and use normative standards

Coordinate best practices with partners:

- both private and public health insurers should be able to share information

Conduct more data analysis:

- regular mining of data to look for trends, profile providers, Aspikes@ in billing

Reconcile Privacy Act issues:

- may need to re-examine the Privacy Act, particularly related to data sharing and information sharing targeted at preventing and detecting fraud and abuse


Improve and evolve enforcement efforts and tools:

- implement mechanisms for private entities to be able to take fraudulent providers or Abad actors@ to court and supplement the federal government

- provide fraud training for beneficiaries and providers

- sentencing guidelines need to be re-evaluated: increase punishment for violations — longer jail sentences, higher monetary penalties; punishment should be equal to the crime

- change approach to prosecuting white collar crime; investigative processes should be more intense — similar to other types of crime

- promote a more consistent approach to developing and prosecuting health care fraud cases


Promote and foster communication:

- increase communication between and among beneficiaries, advocacy groups, providers and government (state and federal)

- engage providers to educate beneficiaries

- contract with advocacy groups to educate beneficiaries

- end Aturf battles@ among agencies

- allow peer review organizations, carriers, and fiscal intermediaries to hold meetings without requiring HCFA approval

Future Implications

Future Challenges

Expansion of preventative services

Have a clear differentiation of all the terms — fraud, waste, and abuse — and we need different strategies to address each one. Our technology has to be able to differentiate between fraud, waste, and abuse. Law enforcement strategies also should be differentiated in addressing these three areas.

Be aware of the extent that fraud and abuse efforts impact quality of patient care

Work to stay abreast of the rapid changes in technologically based fraud

Increase partnering with providers

Find consensus and buy in on the problems– maybe use the Medicare Commission as a vehicle for discussion

Connect fraud, waste, and abuse to quality issues, but will have to address the politics of this

Work to reduce the predictability of audit programs. Predictability makes it easy to Afly under our radar@

Allow time to enhance our workforce — need training and education and expectation that results may come later

Define, prevent and detect fraud, waste, and abuse in managed care

Develop ways to objectively and quantitatively evaluate contractors

Build trust with providers and beneficiaries

Acquire and retain more and most appropriate resources (funds and personnel) to combat fraud and abuse

Resolve ALJ and appeals process issues


Increase oversight of contractors

Coordinate data and use of systems

Decision makers must see improvement of systems as a short term cost with the benefit of savings over time

Develop and coordinate strategies among all entities involved

Develop compliance and ethics control system

Re-examine current incentive systems for insurers and providers

Starting in medical school, educate providers about fraud, waste and abuse

Source: www.hcfa.gov/medicare/fraud/summary3.htm

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