By William Root, Assistant Special Agent in Charge, HEAT Medicare Fraud Strike Force, Office of the Inspector General
Mr. Root leads Medicare fraud and abuse investigative efforts for Louisiana where he is responsible for determining if a case merits criminal investigation or administrative action. He was a speaker at the 2011 eQHealth Louisiana Medicare Quality Summit & Awards program in April. Mr. Root offered the following tips on avoiding Medicare fraud and abuse to the Summit provider attendees.
Sending Medicare a bill for services that were never provided to patients is fraud. Knowingly doing something illegal is where the line between fraud and abuse is crossed. Abuse is accidental. Health care providers may run into problems with Medicare abuse if they are unaware of the activities that conflict with current laws.
Here are a few steps providers can take to avoid unintentional Medicare abuse:
1. Educate yourself and your staff on fraud and abuse laws
• Make compliance education a priority and a routine:
- Physicians can review the OIG’s fraud and abuse training materials for providers.
- Office/business managers and billing staff should check the OIG website once a year to stay informed about important regulation changes, such as billing procedures, contracts and referring practices. Instances of unintentional abuse are frequently the result of providers incorrectly coding and billing Medicare services.
- Hire a medical review or CPA firm to complete a yearly external audit.
2. Identify and monitor your abuse risk areas
• Health services companies often give physicians incentives per prescription for:
- Imaging and radiology services
- Durable medical equipment and supplies
• Medical equipment and supplies companies also target physician offices by faxing referrals on behalf of their patients.
- It is important for physicians to check the patient’s medical record to make sure the equipment is needed because it is unlikely that the company assessed the patient.
- Physicians should be wary of forms that have a lot of empty spaces. A common tactic is to add on items. For example, the physician may sign off on a cane for the patient but the company adds a wheelchair or a total body arthritis kit that includes knee, elbow and back braces.
3. Use caution when you enter into financial relationships
• Some agreements with other providers and health care vendors conflict with anti-kickback and self-referral laws.
- For example, physicians should be careful of contracts with hospitals that offer a favorable office space lease with a promise for patient referrals to the hospital.
- Hospitals should be cautious when entering into contracts with ancillary clinical services companies, such as laboratories. For example, a contract providing discounts for purchasing large lab packages could result in medical staff up coding lab services, such as running a multiple panel blood test when it’s not really necessary.
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Additional fraud and abuse resources for providers:
• OIG tips for how to handle a potential issue with Medicare abuse.
• Providers in Louisiana can report potential Medicare fraud and abuse to the La. Senior Medicare Patrol or you can find the SMP organization in your state here.
• American Medical Association compliance resource.
• Summary of compliance priorities for hospitals from the OIG 2011 Work Plan.
• Watch the HEAT Provider Compliance Training Webcast here.
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