Avoid health care fraud with a compliance culture
Published: 2010-01-08 12:19:59
Author: Pamela Enslen | mlive.com | January 6, 2010
Last spring, a Medicare Fraud Strike Force team, known as the Health Care Fraud Prevention & Enforcement Action Team, or HEAT, was formed by the U.S. Departments of Justice and Health and Human Services to investigate and prosecute health care fraud.
HEAT is a joint task force of senior leaders from the DOJ and HHS and is also comprised of state and local investigators. Strike Forces around the country, including in Detroit, have been extremely successful at prosecuting offenders, resulting in cases against 249 individuals and leading to the recovery of over $265 million in court-ordered restitution.
The types of fraud investigators are looking for include false statements on Medicare forms, kickbacks in exchange for Medicare referrals, and billing fraud, which includes billing for services never provided, billing for unnecessary tests, and double-billing.
Investigators use computer technology and quantitative analysis of data to detect fraud. Investigators also rely on community self-policing, anonymous tips and interviews with Medicare beneficiaries.
Investigators look for certain red flags, which could suggest fraudulent activity. Here are a few examples:
• A single diagnosis or same treatments for all patients
• Rare and expensive treatments or services
• A lack of follow-up care
• Geographic disparity among patients
• Inconsistent diagnoses for the same patient
• A doctor treating too many patients
Honest practitioners may find themselves the subject of an investigation if a red flag is falsely raised. To avoid such an investigation, practitioners should proactively protect their practice.
Implement detailed record-keeping for ordered services to ensure they are necessary and actually rendered. Specify in writing why services or tests were ordered. Do not leave this to the Medicare provider who files the claim.
Full story
Published: 2010-01-08 12:19:59
Author: Pamela Enslen | mlive.com | January 6, 2010
Last spring, a Medicare Fraud Strike Force team, known as the Health Care Fraud Prevention & Enforcement Action Team, or HEAT, was formed by the U.S. Departments of Justice and Health and Human Services to investigate and prosecute health care fraud.
HEAT is a joint task force of senior leaders from the DOJ and HHS and is also comprised of state and local investigators. Strike Forces around the country, including in Detroit, have been extremely successful at prosecuting offenders, resulting in cases against 249 individuals and leading to the recovery of over $265 million in court-ordered restitution.
The types of fraud investigators are looking for include false statements on Medicare forms, kickbacks in exchange for Medicare referrals, and billing fraud, which includes billing for services never provided, billing for unnecessary tests, and double-billing.
Investigators use computer technology and quantitative analysis of data to detect fraud. Investigators also rely on community self-policing, anonymous tips and interviews with Medicare beneficiaries.
Investigators look for certain red flags, which could suggest fraudulent activity. Here are a few examples:
• A single diagnosis or same treatments for all patients
• Rare and expensive treatments or services
• A lack of follow-up care
• Geographic disparity among patients
• Inconsistent diagnoses for the same patient
• A doctor treating too many patients
Honest practitioners may find themselves the subject of an investigation if a red flag is falsely raised. To avoid such an investigation, practitioners should proactively protect their practice.
Implement detailed record-keeping for ordered services to ensure they are necessary and actually rendered. Specify in writing why services or tests were ordered. Do not leave this to the Medicare provider who files the claim.
Full story