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Posts Tagged ‘Medicare’

Audits Are Increasing “Thanks” to New Healthcare Laws

Wednesday, May 25th, 2011

Hospitals and physicians are experiencing a great number of audits due to new reform laws that hope to reduce healthcare fraud, waste, and abuse. The most recognizable type of audit – RAC (Recovery Audit Contractors) are paid on a contingency basis – meaning they do not get paid unless they discover the hospital or the specific provider is billing incorrectly or other audit rules that may apply.

What you may not know is that the government has MULTIPLE types of audit programs out there looking into hospitals, home health agencies, individual providers, and DME (durable medical equipment) companies in order to decrease reimbursement for coding issues, lack of documentation, and inaccurate documentation among many other things.

What types of audits should you be prepared for?

  • MAC (Medicare Administrative Contractor)

o   Compliance with ADMINISTRATIVE COSTS

  • PSC (Program Safeguard Contractor)

o   Looking for FRAUD, WASTE, & ABUSE

  • ZPIC (Zone Program Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • MEDIC (Medicare Drug Integrity Contractors)

o   Looking for FRAUD, WASTE, & ABUSE

  • RVC (Recovery Audit Validation Contractors)

o   Looking for OVERPAYMENTS

  • QIC (Qualified Independent Contractors)

o   Compliance with ADMINISTRATIVE COSTS

  • MIC (Medicaid Integrity Contractors)

o   Compliance with PROGRAM INTEGRITY

Why is this happening?

According to the “Summary of the 2008 Financial Report of the United States Government,” in 2008, Medicare hospital insurance benefits began to exceed program tax revenues.

The bottom line is there is not enough money. Private insurance companies are following suit – the application of contractor audit methods are being applied RIGHT now.

Remember, it is not about preparing for any particular “audit” program – it is about developing internal controls, effective mitigation strategies, and an effective response to any third party.

Thanks for reading!

Your healthcare resource – Rebecca Busch

Chicago – New Healthcare Fraud Hot Bed?

Tuesday, April 19th, 2011

Medicare fraud is hitting Chicago – hard. Chicago’s vulnerable population of senior citizens is receiving the brunt of the fraud, with the unethically targeting nursing homes and elderly living communities. A recent scheme involving elderly immigrants and durable medical equipment was snuffed out by authorities, but not before the fraudsters stole Medicare ID numbers.

Other recent Chicago healthcare fraud schemes include:

Dr. Jaswinder Rai Chhibber, owner of Chicago’s Cottage Grove Community Medical Clinic – charged with ordering unnecessary diagnostic tests for seniors and other patients in an effort to boost revenues from Medicare and Medicaid. Tests included echocardiograms, electrocardiograms and lung function tests, among others.

Marilyn Maravilla, a Chicago nurse, and four others were charged in a criminal complaint with paying kickbacks to various health care providers in exchange for referrals to her agency, Goodwill Home Healthcare Inc. of Lincolnwood. This fraud is part of a bigger, $200 billion scheme brought down by the HEAT taskforce.

Virgilio Orillo and Merigrace Orillo, owners of Chicago’s Chalice Home Healthcare Services Inc., were charged in a criminal indictment with falsifying documents in an effort to boost Medicare payments. The alleged scam, according to the government: Patients were listed as being homebound and in need of skilled assistance when it wasn’t true. (Medicare pays for home health care only for patients who meet these criteria.)

Thanks for reading!

Your healthcare resource – Rebecca Busch

All Eyes on Compliance with New Whistleblower Laws

Thursday, September 23rd, 2010

With the new laws and incentives reported in the Patient Protection and Affordable Care Act, we are seeing more whistleblowers come forth alleging healthcare fraud. Currently, 90% of health care fraud cases are whistleblower cases — often in which the behavior of the “ethically challenged” directly poses risks to public health.

Regardless of whether whistleblowers are concerned citizens, disgruntled employees or senior executives with a “lottery mentality”, hospitals and other healthcare companies must have strong compliance programs in place to stop fraudulent activity — such as improperly billing Medicare and Medicaid and kickbacks to doctors. A list of healthcare companies that have signed corporate integrity agreements with the OIG can be found here.

With the new incentives, hospitals and other healthcare companies are even more susceptible to whistleblowers. Now is the time to review your current compliance program and develop the necessary internal controls to protect your organization from committing fraud. Below are 4 simple but important considerations to keep in mind when evaluating compliance programs:

1. Periodic comprehensive fraud risk assessments are conducted.
2. Standards of conduct for employees are written and distributed.
3. Educational and training programs are offered to all employees.
4. Audits are conducted to monitor compliance and identify problem areas.

The effectiveness of whistleblowers is also an integral part of the effort to combat healthcare fraud. The first thing people need to do when encountering fraudulent activity in their workplace is to make sure that they understand the reporting framework and seek appropriate legal counsel. As an expert witness, I have seen first-hand the enormous complexity of whistleblower suits.

Fighting Fraud with Pre-Payment Claims Review

Wednesday, August 25th, 2010

Earlier this summer, the U.S. Government Accountability Office (GAO) released a report identifying the challenges that CMS faces in implementing strategies to prevent overpayments and fraud, waste, and abuse — including focusing on pre- and post-payment claims review on the most vulnerable areas.

Our administration has set battling healthcare fraud, waste and abuse as a high priority. A recent study found $835 million in questionable Medicare payments identified by private contractors in 2007.

Some states are following suit for their Medicaid programs. The Illinois Department of Healthcare and Family Services also recently issued a report on the efficiencies and improvements in the Illinois Medicaid program that included measures to prevent Medicaid fraud and overpayments by contracting with third parties to conduct payment and recapture audits. The State of Indiana also recently issued a Request for Services to detect fraud, waste and abuse in its Medicaid program.

It is also important to stop money from going out-the-door in the first place. Preventing inappropriate payments can be easier than “recovering” inappropriate payments after the fact — as evidenced by that fact that perpetrators often “close shop” and move on when they are notified of claim disputes. The GAO calls for Medicare to improve the pre-payment review of claims. As predictive modeling technologies continue to evolve pre-payment claim review will become a critical tool to combating fraud.

The “ethically challenged” understand the amount of money in healthcare – and do not limit their prey to government sponsored programs. It is critical for private payers, plan administrators and self-funded employer plans to follow suit in both pre- and post-claim review.