BHA-FPX4006_Assessment 2-1.docx

Identifying and Addressing Healthcare Fraud and Abuse Capella University BHA-FPX4006: Healthcare Regulation and Compliance 1

Identifying and Addressing Upcoding Major Categories of Healthcare Care Fraud and Abuse Category of Health Care Fraud and Abuse Description of Category and Example from Authoritative Source* Medical Identity Theft CMS defines medical identity theft as "the misuse of a person's medical identity to receive healthcare services, goods, or funds." For example, a person may obtain someone else's Medicare Beneficiary Identifier (MBI), impersonate the individual, and receive medical care. Billing for Unnecessary Services or Items This type of fraud is when a clinician bills Medicare or a private insurance company for services deemed "medically necessary" but was not. An example of this type of fraud and abuse is a physician performing procedures, such as cancer treatments, which were not needed. Billing for Services or Items not Received This occurs when a healthcare professional bills for a covered item, such as durable medical equipment, provided to patients but never received. CMS provided an example in which a Medicaid personal care attendant billed for care provided to a patient and forged

Category of Health Care Fraud and Abuse Description of Category and Example from Authoritative Source* the patient's signature to receive payment. Upcoding This type of fraud is defined as billing for higher complex evaluations instead of standard or essential services provided. According to CMS, Medicaid audited a psychiatrist who billed patients for 20-minute sessions, but they were only 5 minutes or less. Unbundling Unbundling encompasses a healthcare professional submitting claims as separate line items to receive a higher reimbursement instead of combining the services as necessary and receiving the appropriate payment, which may be at discounted rates from the insurance company. For example, a lawsuit settled for $1 million due to a physician billing for anesthesia and cardiac services separately, although they had been performed together (Coutasse, 2021). Kickbacks According to CMS, a kickback is soliciting or receiving compensation in return for patient referrals or assistance with generating business. Compensation is usually paid through federal health care programs. An example would be a physician receiving compensation

Category of Health Care Fraud and Abuse Description of Category and Example from Authoritative Source* from a pharmaceutical company for referring or prescribing a specific medication.

Five Health Care Fraud and Abuse Laws Number Health Care Fraud and Abuse Law Description of Law Rationale: How Does This Law Apply to Health Care? 1. False Claims Act The False Claims Act (FCA) is a federal law that imposes liability on individuals or companies that knowingly submitted false or fraudulent claims to government programs such as Medicare and Medicaid for payment. According to the Office of Inspector General (OIG), individuals who act in "deliberate ignorance" or "falsity of information" are also found liable. The penalties for filing false claims may result in fines up to $11,000, plus three times the government's sustained loss. Individuals who submit false claims can be The purpose of the FCA is to recoup funds obtained through fraudulent activity. The act protects the government from being overcharged, ensures program integrity, and promotes accountability in the healthcare system.

Number Health Care Fraud and Abuse Law Description of Law Rationale: How Does This Law Apply to Health Care? personally subjected to fines up to $250,000 and 5 years imprisonment and may be excluded from participating in Federal healthcare programs (CMS, 2016). 2. Federal Anti-Kick Back Statue The OIG states that the Anti-Kick Back Statute (AKS) prohibits the "remuneration" to induce or reward for patient referrals or assistance generating business referrals involving Federal healthcare programs. The kickbacks may be in the form of cash, discounted services, professional positions, or gifts. Clinicians who pay or accept kickbacks Prohibiting kickbacks ensures that medical decisions are in the best interest of the patient rather than the receipt of financial incentives. Additionally, it prevents increased costs, unfair competition, and overutilization of services.

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