Guide to recognizing and reporting Medicare fraud and abuse. Contact information and what info you need to provide when reporting it. Did you know you may qualify for a reward?
We’ll give an introduction to how Medicare fraud is defined, how to report it, information to report, and what happens when fraud is reported. Basically everything that applies to Medicare fraud discussed here also applies to Medicaid fraud.
What is Medicare Fraud?
Medicare fraud and abuse typically falls into three categories:
False Claims
The False Claims Act
establishes civil and criminal penalties for anyone that submits claims to
Medicare for services that were not performed or medical supplies that were not
provided. This also includes items or services that are substandard. An example
of false claims is when a provider submits a Medicare claim for medical
services or equipment that was not provided to the patient. Fines imposed for violating
the False Claims Act can be up to 3 times the damages caused to the government.
Deliberately altering claims to receive a higher payment would also be considered a false claim. Other examples would be listing diagnosis and treatment codes and modifiers that are not accurate in order to receive a higher payment and excessive charges for medical services and supplies.
Medicare fraud may range
from a small practice to a large organized effort by an organization,
institution, or group practice.
Kickbacks
Kickbacks are a form of
Medicare fraud which involves paying or soliciting someone for referrals of
medical services or items that are then reimbursed by Medicare. There is an
anti-kickback law that makes it a criminal offense to solicit, pay or receive
any payments for referrals of services or items that are reimbursed by a
Federal healthcare program - such as Medicare or Medicaid. Penalties for
violating the Anti-Kickback law can include fines, prison, or both.
Physician Self Referral
A law called the Stark
Law was created to prevent a physician from referring a patient for health
services to an organization in which he or she has an interest. This interest
could be ownership or partial ownership by the physician or a family member, an
investment interest, or a compensation arrangement.
Reporting Medicare Fraud - Contacts
Here is the contact
information for reporting Medicare or Medicaid fraud.
If you are a Medicare Beneficiary (Insured by Medicare):
CMS Hotline: 1-800-MEDICARE (1-800-633-4227)
For Medicare Managed Care or Prescription Drugs: 1-877-7SafeRx (1-877-772-3379)
If you are a Medicare Provider:
Office of Inspector General Hotline
Phone: 1-800-HHS-TIPS (1-800-447-8477)
Fax: 1-800-223-8164
E-mail: [email protected]
Mailing Address:
US Department of Health and Human Services
Office of Inspector General
Attn: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
Or you can report
through your Medicare Administrative Contractor (MAC) - your local contractors
who administer Medicare.
If you are a Medicaid
Provider or Insured:
OIG Hotline
Phone: 1-800-HHS-TIPS (1-800-447-8477)
Fax: 1-800-223-8164
E-mail: [email protected]
Mail:
US Department of Health and Human Services
Office of Inspector General
Attn: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
You may also report to
your Medicaid State Agency Fraud Unit which you can search for here.
What Info to Provide When Reporting
When reporting Medicare
fraud, the U. S. Government recommends having the following information before
you report:
What Happens When Reporting Medicare Fraud
Medicare fraud can be
investigated by a variety of government agencies, the most likely to be the US
Attorney Office, the Department of Justice (DOJ), and the Office of Inspector
General (OIG) - which is part of the Department of Health and Human Services
(HHS). The DOJ agency would be the Federal Bureau of Investigation (FBI).
Investigations conducted by the DOJ or US Attorney’s Office are usually in
cooperation with the OIG since healthcare fraud abuse and prevention is the
responsibility of the HHS/OIG and because of their expertise in healthcare.
The HHS OIG has the ability and expertise to conduct audits and investigations into healthcare fraud and can impose penalties of their own as well as prevent healthcare providers from participating in federal programs such as Medicare or Medicaid.
The Centers for Medicaid and Medicare Services (CMS) which administers Medicare also has a program called Programme Safeguard Contractors (PSC). This program contracts with several companies to monitor and review claims to insure compliance with CMS standards. If suspicious activity is detected, the PSC contractor can recommend payment suspensions and refer the case to the appropriate law enforcement agency.
In addition to federal agencies, many states have Medicare and Medicaid fraud and abuse monitoring programs. All states administering Medicaid benefits will have Medicaid fraud programs responsible for investigating and prosecuting fraud and abuse.
Enforcement Agencies
There are several
government agencies and partnerships set up to fight fraud with the Centers for
Medicare and Medicaid Services (CMS) being the lead organization. Here’s the
primary resources CMS has to report and combat Medicare fraud.
Office of Inspector General (OIG)
The OIG is tasked by the
Department of Health and Human Services, of which CMS is a part of, to protect
Medicare from fraud and abuse. They accomplish this by conducting audits,
inspections, and investigations. When the OIG has determined violations have
occurred, they have the authority to exclude the offenders from participating
in Medicare or Medicaid programs and imposing monetary penalties - or fines -
on the offending parties.
Health Care Fraud Prevention and Enforcement Action Team (HEAT)
HEAT is a joint team
between the Department of Justice (DOJ) and Health & Human Services to
strengthen federal programs and establish new processes and technology to
combat Medicare fraud. An example of their efforts is the Stop Medicare Fraud
website (http://www.stopmedicarefraud.gov) which provides guidance on identifying and
reporting fraud.
General Services Administration (GSA)
The U. S. General
Services Administration keeps a list of those who cannot participate in federal
government programs. This means they cannot receive federal contracts, aid, or
non-monetary benefits.
Rewards
Under certain
conditions, those reporting Medicare fraud can be eligible for a max $1,000
reward. To qualify, the following conditions must be met:
The alleged medicare fraud is confirmed by the responsible federal agency or contractor and referred to the Office of Inspector General.
Summary
It's important to recognize and combat Medicare fraud and abuse. Not only is it unethical and costs taxpayers billions of dollars, but your practice or organization could be vulnerable. It's important to recognize abuse of the Medicare/Medicaid system. Reporting Medicare fraud promptly protects your organization from civil or criminal penalties - or both.
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Mar 31, 18 09:47 AM
Besides networking .. visiting their offices, how else can you attract their business? When you close the collections month, how do you bill the physicians?
Mar 31, 18 09:36 AM
I have a potential client that is requested claim scrubbing resolutions (only corrections on claims submission errors) and insurance verification on the
Mar 31, 18 09:28 AM
The provider that I bill for just advised that he has a new tax ID. What is the process for this change? Would every insurance company need to be contacted?
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