Health Care Fraud - Don’t Do It!

July 31st, 2017 - Chris Woolstenhulme, CPC, CMRS
Categories:   Insurance   Compliance  

If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely seriously. I don't need to tell you this. 

I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate claim? In short, fraud is an intentional deception or misrepresentation.   

Let’s not panic; there is a distinction between intentional fraud and an error. In regards to the 46 year old Denver woman, it was proved to be intentional. This was not an accidental duplicate claim.

The OIG posted this article on July 27th, 2017. 

"Denver Woman Sentenced To 46 Months’ Imprisonment for Health Care Fraud"

The US attorney’s office reported, “According to United States Attorney Bruce D. Brandler, as a result of prior convictions relating to Medicaid fraud, Sensenig was excluded from providing healthcare to Medicaid beneficiaries. In order to obtain a position as a behavioral health consultant, Sensenig made false representations, including a forged background check, in order to hide her ineligible status. As a result, Medicaid paid approximately $84,500 for her services."

USA Today reported on July 13th, 2017:

"Jeff Sessions: 400 medical professionals charged in largest health care fraud takedown"

“Sessions said the suspects accounted for more than $1.3 billion in fraudulent transactions across more than 20 states, and at least 120 people were charged for their alleged roles in overprescribing and distributing opioids, making it also the largest-ever opioid-related fraud takedown.

Of the 412 charged in the year-long operation, 56 were physicians.”

Of course, the OIG has a most wanted fugitive list. If you ever decide you want your name on that list and make a contentious decision that is your goal in life, and you no longer need your license you worked so hard for, you can get on this list. Hint: you never want to be on that list, but just in case you have any questions about how to get on it, here are just a few areas of conduct that will certainly place your name on the OIG’s most wanted list.

  • Bill Medicare for durable medical equipment (DME) and supplies that either were not provided or were medically unnecessary
  • Conspiracy to defraud the United States
  • Commit health care fraud
  • Pay kickbacks
  • Money laundering 
  • Conspiracy to commit money laundering
  • Medical treatments that were never provided or were medically unnecessary
  • Aggravated identity theft
  • False claims
  • False statements related to health care matters
  • Falsification of records
  • False Medicare claims for durable medical equipment (DME) that was medically unnecessary or was not provided to beneficiaries

Some of the less obvious but common areas of fraud are just as serious, such as: 

  • Waiving patient co-payments and deductibles
  • Prescribing drugs unnecessarily
  • Inaccurate reporting of patient diagnoses and procedures

This list could go on-and-on. The other side to this is that it's not only payers and the government that pays for dishonest providers; the affect is far-reaching. Starting with the elderly, Medicare beneficiaries are commonly scammed using benefits that count toward a lifetime or other limited benefit. On an even more personal note, it is estimated that American taxpayers will pay between $50-90 Billion annually for Medicare fraud alone.

Most providers follow good medical practices, are outstanding providers, and take their oath seriously. The National Health Care Anti-Fraud Association (NHCAA) states the majority of healthcare fraud is committed by a very small minority of dishonest healthcare providers.”

We can all do our part by keeping an eye out for perpetrators of healthcare fraud. Lowering health care fraud and abuse should potentially begin to lower healthcare costs. This certainly affects all of us personally.

To report Medicare fraud, contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you’re a TTY user, call 1-877-486-2048.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association