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Posts Tagged ‘U.S. Government’

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

Fighting Healthcare Fraud

Friday, November 19th, 2010

All puns aside, the government is really turning up the HEAT on healthcare fraud. HEAT (Health Care Fraud Prevention and Enforcement Action Team) was established in May 2009 to crack down and prevent fraud, waste and abuse in a healthcare system that loses an estimated $60 to $80 billion per year to fraudsters and the “ethically challenged.”

HEAT compliments the joint DOJ-HHS Medicare Fraud Strike Force which is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud using high-tech data analytic techniques and a focus on community policing. Strike Force teams are currently in Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa and Baton Rouge.

The HEAT task force is comprised of top-level law enforcement agents, prosecutors and staff from both the Department of Justice and the Department Health and Human Services.

How is HEAT weathering the storm? By all accounts, this new task force is living up to the hype. Thirty-six people in five different states have been arrested and 94 indicted following an investigation regarding a Medicare insurance scam totaling over $250 million. Investigators apprehended nurses, doctors and other health professionals in Miami, New York, Detroit, Houston and Baton Rouge.

Attorney General Eric Holder was quoted saying, “With [these] arrests, we’re putting would-be criminals on notice: Healthcare fraud is no longer a safe bet.”

What are the fraudsters doing these days? Well, according to reports, NOT getting away with healthcare fraud thanks to the new task force. The government is in hot pursuit of those that are bilking the system.
As an investigator, here are some sure fire tips to help spot fraud in a healthcare setting:

1. Make sure you have a system in process to collect diagnosis and procedure information.
2. Track diagnosis and procedures provided, even if just by volume.
3. By simply having the right information in a single source data base, we can begin to ask the data, “Where is the hanging fruit activity?” For example, how many procedures are done in one day by one provider? How long does a patient wait to be seen? How far apart are the actual treatments?
4. Finally, tracking the different types of healthcare fraud schemes is just as valuable. A common scheme in many countries is falsifying mental and emotional states of an individual as a ruse to steal assets which lead to misrepresenting identity to receive healthcare services.

Regardless, one thing for sure is that we can always depend on the creativity of the ethically challenged.

What is a Prior Approval Law?

Thursday, August 26th, 2010

As the news of expected and enacted premium increases spreads across the country, these state-level legislative measures are receiving more and more attention. Elected officials proudly tout them and insurance companies are already suing states in response to them. Most people, however, don’t know much about prior approval laws.

The term “prior approval law” refers to legislation that grants the officials of a state the power to review and approve health insurance premium increases before they take effect. These laws are passed at the state level and usually give the authority to the State Insurance Department. Without prior approval laws, states are restricted in their ability to regulate premium increases and, de facto or de jure, the insurance industry self-regulates.

Prior approval laws have gained attention as a result of the recent healthcare reform, which affords the federal government limited power to curtail premium increases. Although the federal reform includes provisions such as that which requires insurers to justify “unreasonable” rate increases, much of the power necessary for premium moderation has been left outside the reach of the national government.

Regulating premiums has traditionally been the responsibility of the states, and now, as we continue to see double digit premium increases during this economic crisis, it is more important than ever for states to fulfill this responsibility. It is the disappointing truth that only 19 states currently have prior approval legislation on the books. Of those 19, however, some states are making great progress by enforcing these laws. For example, Oregon officials have modified or dismissed 20 of 71 proffered premium increases in the individual and small group markets since April 2009.

Some consumer advocates and politicians support granting prior approval authority to all states. Doing so would likely end many current lawsuits between insurance companies and states. But the effectiveness of such legislation in suppressing premium increases would depend on politicians’ willingness to resist the influence of the insurance industry.

It is well known that the healthcare insurance industry aggressively lobbies federal officials and helped pen much of the recent healthcare reform. Few realize, however, that the industry exerts significant pressure at the state level as well. Much of that pressure comes from over $42 million in contributions since 2003. Jim Duffett, executive director of the Illinois-based Campaign for Better Health Care, describes the result of excessive lobbying: “State government here has basically been a wholly owned subsidiary of the insurance industry.”

Apparently, insurance companies already know what many of us are just learning; as Washington State Insurance Commissioner Mike Kreidler warns, “The battle has shifted to the states.”

Look for more on this and other healthcare legislation in future posts.

L.A. Times
N.Y. State Government

Schemes to defraud the health system

Wednesday, February 24th, 2010

We all know that healthcare fraud is a growing concern. Private (e.g. Blue Cross Blue Shield, Aetna etc.) and public insurers (e.g. the government – Medicare and Medicaid) are both susceptible to fraud with the latter receiving the biggest hit. We know that fraudsters steal money – but how do they do it? In an article released by the United States General Accounting Office (GAO) they highlight some of the major and most prominent healthcare fraud schemes.

Healthcare Fraud Examples

1. Rent-a-Patient Scheme
In this scheme organizations pay for—or “rent”—individuals to go to clinics for unnecessary diagnostic tests and cursory examinations. The scary thing is that licensed physicians sometimes participate in the rent-a-patient scheme. Case and point: Robert Bourseau, 75, was sentenced to 37 months in prison and ordered to pay $4.1 million in restitution for his role in a scheme to defraud Medicare and Medi-Cal. He pleaded guilty in June to paying a recruiter to deliver homeless patients to his hospital for unnecessary medical services.

2. Pill Mill Scheme
In this scheme, separate health care individuals and entities (usually including a pharmacy) collude to generate a flood of fraudulent claims that Medicaid pays. After a prescription is filled, the beneficiary sells the medication to pill buyers on the street who then sell the drugs back to the pharmacy. Example: Rick Kloxin, pharmacist in charge of Hogan’s Pharmacy in Lyons, Kans., was found guilty in an internet pill mill scheme. Kloxin pled no contest and was found guilty of 14 misdemeanor counts of violating Kansas Pharmacy laws.

3. Drop Box Scheme
This scheme uses a private mailbox facility as the fraudulent health care entity’s address, with the entity’s “suite” number actually being its mailbox number. The fraudulent health care entity then uses the address to submit fraudulent Medicare, Medicaid, and other insurance claims and to receive insurance checks.

4. Third-Party Billing Scheme
The third-party billing scheme revolves around a third-party biller—who may or may not be part of the scheme—who prepares and remits claims to Medicare or Medicaid (electronically or by paper) for health care providers. It is possible, however, for a third-party biller to defraud Medicare, Medicaid, and others by adding claims without the providers’ knowledge and keeping the remittances or by allowing fraudulent claims to be billed to Medicare or Medicaid through its service. Example: Recently, in Miami, Ihosvany Marquez and several alleged conspirators were indicted on charges of having filed $55 million in phony Medicare claims for HIV, AIDS, cancer, pain and varicose vein treatments.

False Claims Act and Healthcare Fraud Reporting

Thursday, December 24th, 2009

The False Claims Act was passed by Congress in 1863 and allows people who are not affiliated with the government (Congressmen, the President etc.) to file actions against federal contractors claiming fraud against the government.

In our current economic forecast with fraud running rampant (the Madoff scandal, the collapse of the financial market etc.) the False Claims Act is still relevant. Even with the abundance of accounting fraud, the major focus of the False Claims Act is still healthcare fraud. According to an article in the American Medical News, “Healthcare cases made up the lion’s share of false claims settlements and judgments in the fiscal year, brining in $1.6 billion, or two-thirds of the total $2.4 billion recouped.

Read full article here.

Healthcare fraud is a huge industry for the ethically challenged in our country. Keep reporting – it is a great deterrent.

Medical Business Associates, Inc. advances to Innovate Illinois semi-finals

Tuesday, September 8th, 2009

Medical Business Associates, Inc. has been chosen as one of the 30 semi-finalists (over 130 companies applied) for Innovate Illinois – a statewide entrepreneurial and innovation competition recognizing high-growth entrepreneurs.

The next round of the competition, taking place September 24th at the University of Illinois Urbana-Champaign, includes a 5-minute pitch followed by a short question and answer session.

Grand prize is $30,000 in grant money. Good luck Rebecca Busch and Medical Business Associates!

Read more about Innovate Illinois.

The evolution of health insurance

Tuesday, September 1st, 2009

In 1927, on the eve of the Great Depression, Baylor Hospital in Dallas entered into an agreement with the local teachers’ union. The agreement involved an employee deduction per paycheck paid in advance to the hospital. In turn, the hospital offered hospital-based care for these teachers and their families. This deduction was determined using a community-based rating model. Eventually, an organization known as Blue Cross emerged and started to provide the same type of program. Note, however, that a model known as prepaid practice groups (PGPs) already existed. Prior to this time period, private insurance did not exist for healthcare services. Health insurance offerings were avoided because appropriate premium rates were too difficult to predict, unlike rates for insurance upon the death of an individual. Private insurance plans started to appear in the late 1930s. These plans, however, were driven by risk-based models. They focused on the experience of the group. Blue Cross now had competition and was losing its customer base because of the new private-payer offerings. Blue Cross shifted toward a modified adjusted community rate plan, eventually abandoning it completely and joining the private-payer risk model plans. Eventually Blue Shield emerged to serve coverage for professional services.

This introduction illustrates one of the very first critical “cost shifting” market movements. What does cost shifting mean? It is when the cost of certain activities is shifted to another party. The question is, to whom? Private payers profited by removing high-risk individuals from their plans – they were growing at a rapid rate because during WWII a wage hold was put into place. Employers started to realize that benefit plans could be seen as a non-wage form of compensation. The tax code encouraged employers to view benefit plans as a cost of doing business, and employees never had to claim their benefits as income.

The benefit plan offering generated a significant amount of cash in the healthcare system. During the 1940s and going forward, teaching hospitals were also recipients of large amounts of cash infusion by the government’s investment in research and technology. The flow of cash from both areas generated a significant offering of healthcare diagnostics and treatment options. By 1946, the healthcare market had increased cash flow for hospital coverage. This resulted in increased utilization of hospital services. The amounts of insurance payments and premium programs went up. Hospitals expanded because of the available cash. The market had a significant buildup of resources. The amount of technology was growing at an accelerated rate. This fueled additional use and sale of insurance. The gap between the haves and have-nots exploded. From 1930 to 1965, there was the first big cost shift of high-risk individuals to uninsured status. Who were these people? They were the elderly, the unemployed, the self-employed, the retired and the disabled. With the aggressive advancements in healthcare, the disproportionate offerings between the haves and the have-nots became obvious.

The political arena debated the concept of compulsory insurance or a nationalized health plan. Instead, in 1965 Medicare was born to serve the have-nots. Medicare takes a social insurance approach, and its members are referred to as beneficiaries. Medicaid was also established; it is managed at the state level. Medicaid, however, uses a welfare approach, and its members are referred to as recipients. The market at the time believed that employer-linked insurance would eventually serve as a form of nationalized health insurance. Medicare Part A was created to pay hospital services, and Medicare Part B was created to serve the professional component. To devise a nationalized healthcare program was not necessary. The market, it was thought, would take care of itself.

Excerpt from Healthcare Fraud Auditing & Detection Guide by Rebecca Busch

A Government bill to help reduce healthcare fraud? Finally.

Friday, July 31st, 2009

Healthcare fraud is a $60 billion industry. Fraud “rings” are popping up all over the country mainly because stealing from healthcare providers, patients and government run health programs is safer and easier than being a drug dealer. How can we deter criminals from stealing money from our already troubled healthcare system? Well, if the House of Representatives has anything to do with it, the proposed IMPROVE (Improving Medicare and Medicaid Policy for Reimbursements through Oversight and Efficiency) Act will hopefully provide enough barriers that criminals will find drug dealing/other crimes more lucrative.

The bipartisan bill would end the common practice of mailing reimbursement checks to post office boxes. However, we first should all be asking a very important question. Who thought it was responsible to send reimbursement checks to post office boxes in the first place? What reputable healthcare provider doesn’t have a permanent address where to send checks?

The Act will mandate that all government sponsored health programs pay healthcare providers and suppliers by using direct deposit. This certainly seems to be a step in the right direction and into the 21st century. Direct deposits will eliminate an easy way for criminals to get their hands on reimbursement checks, save the government money on stamps, envelopes, paper check etc., and don’t forget about the environment.

Congress, please say, “Yes,” to healthcare reform.