Abstract
Health Information Services managers must ensure that all new hires receive training so they can abide by all federal and state laws to effectively promote provider compliance of the regulatory requirements of the Centers for Medicare and Medicaid to enforce procedures to detect and prevent fraud, waste, and abuse in receiving payments from federal health care programs.
Acronyms: FCA,CMS,IPPS,DRG,OPPS,APC,SNF,PDPM,PPS,FFS,RBRVS,VBS,HCPCS
The False Claims Act (FCA) is the enforcing mechanism that investigates and prosecutes against wrongdoers who misuse Medicare and Medicaid to commit fraud and abuse and may activate civil and/or criminal interventions when investigated claims are substantiated, a liability to the United States Government creates a civil penalty of not less than $5,000 and not more than $10,000, as adjusted by the Federal Civil Penalties Inflation Adjustment Act of 1990 (28 U.S.C. 2461) fines can be imposed up to three times the amount for each false claim prosecuted.
Centers for Medicare and Medicaid Fraud and Abuse definitions
1. “Fraud is the intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s)”. (“glossary, cms.gov”)
2. “Fraud is to purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Abuse is payment for items or services that are billed by mistake by providers but should not be paid for by Medicare”. (“glossary, cms.gov”)
Federal False Claims Act – 31 U.S.C. §§ 3729 - 3733
Compliance with state and federal law is an express condition to receive payments from Medicare and Medicaid programs. Providers who falsely certify compliance with these rules may be held civilly liable to whistleblowers, the government, or qui-tam provision of the False Claims Act.
Medical Record and Billing Compliance.
All covered entities employed by a contracted provider or provider organization that supplies health care services to Medicare or Medicaid program enrollees assumes the risk and may be liable under the false claims act if found guilty of fraud and abuse practices as defined by the Centers for Medicare and Medicaid definition.
Health Information Services team members must employ regular compliance audits of claims, ensure use of correct code-sets, and that proper documentation is provided.
Any team member who is witness to any incident of suspected non-compliant billing activities or claims violations, unethical business arrangements or any conduct that the workforce professional has been trained to identify as a potential liability of fraud or abuse of a government program while under contract, must be reported to the Compliance Office immediately. Employees may also invoke a Whistle blower claim or the qui-tam investigation provisions of the False Claims Act.
Reimbursement Methodologies
The inpatient prospective payment system (IPPS) is a structure of payment that groups inpatient acute care hospital settings. "Diagnosis Related Groups (DRG)” is a classification system that groups patient services according to diagnosis, type of treatment, age, and other relevant criteria, and is widely used for reimbursement of inpatient services”. (“Schieber G., 1986, "Prospective payment for Medicare skilled nursing facilities: background and issues." Health Care Finance Rev”)
A skilled nursing facility (SNF) is a nursing home that co-ordinates skilled nursing care and rehabilitation services in an after-care hospitalization setting. “In October 2019, the Patient Driven Payment Model (PDPM), utilized a new case-mix classification system for classifying SNF patients in a Medicare Part A covered stay into payments groups under the SNF Prospective Payment System (PPS)”. (“Office of Inspector General”)
Outpatient Prospective Payment System.
"The hospital outpatient prospective payment system (OPPS) in place today classifies all hospital outpatient services into Ambulatory Payment Classifications (APCs)." (“Medicare's Hospital Outpatient Prospective Payment System: OPPS 101, para. 2,”) The Ambulatory
Payment Classifications payment rate is wage adjusted to rationalize differences of geographics and other components in the group for services. Hospitals that are assigned to the outpatient prospective payment system, do not use the Ambulatory Payment Classifications codes to bill. ”Centers for Medicare and Medicaid requires line-item billing using the HCPCS codes because these codes are frequently moved from one Ambulatory Payment Classifications to another in the annual updates. The claims administrator receives the claims and applies the correct Ambulatory Payment Classifications payment rates to the HCPCS codes.” (“Guidi, T., Medicare's Hospital Outpatient Prospective Payment System: OPPS 101, para. 8”)
Physician’s reimbursement methods, include the current fee for service (FFS) model, that pays physicians for their services after delivery. “Another payment system for reimbursement of physician and other practitioner services is based on a modified version of the Resource Based Relative Value Scale (RBRVS) adopted by the Medicare Program. Health care reform’s new mantra is value-based reimbursement (VBR), a model that incentivizes physicians’ to provide quality care rather than high quantity care”. (“Baig, M, n.d., para. 3”)
References
Baig, M., (n.d.) "Retrieved from Physician Reimbursement Models Is pay for performance the best replacement for fee for service?"
CMS, Glossory, https://www.cms.gov/glossary?term=fraud&items_per_page=10&viewmode=grid
Guidi T. U. (2010). "Medicare's Hospital Outpatient Prospective Payment System: OPPS 101" (part 1 of 2). Journal of oncology practice, 6(6), 321–324 para 2, and 8.. https://doi.org/10.1200/JOP.2010.000163
Office of Inspector General, "Skilled Nursing Facility Reimbursement U ...," https://www.oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000575.asp.
Schieber G, Wiener J, Liu K, Doty P. (1986 Fall;) "Prospective payment for Medicare skilled nursing facilities: background and issues." Health Care Finance Rev.8(1):79-85. PMID: 10311780; PMCID: PMC4191529.
Footnotes
Many of the Fraud Section’s cases are suits filed under the False Claims Act (FCA), 31 U.S.C. §§ 3729 - 3733, a federal statute originally enacted in 1863 in response to defense contractor fraud during the American Civil War.
The FCA provided that any person who knowingly submitted false claims to the government was liable for double the government’s damages plus a penalty of $2,000 for each false claim. The FCA has been amended several times and now provides that violators are liable for treble damages plus a penalty that is linked to inflation.
In addition to allowing the United States to pursue perpetrators of fraud on its own, the FCA allows private citizens to file suits on behalf of the government (called “qui tam” suits) against those who have defrauded the government. Private citizens who successfully bring qui tam actions may receive a portion of the government’s recovery. Many Fraud Section investigations and lawsuits arise from such qui tam actions.
The Department of Justice obtained more than $5.6 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2021. More information about those recoveries can be found here and the 2021 FCA statistics can be found here.
Updated February 2, 2022 - DOJ.gov
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