Avoid common fraud and abuse misunderstandings
By Elizabeth E. Hogue, Esq.
Attorney
Burtonsville, MD
Many providers are generally familiar with prohibitions against fraud and abuse in the Medicare and Medicaid programs, including Medicaid waiver programs. Fraud and abuse in the Medicaid program in the form of billing for services that were never actually provided to patients, for example, may be especially familiar to staff.
Here are two common misconceptions about fraud and abuse among providers:
1. Many staff members misunderstand what it takes to prove intent, a necessary component of fraud and abuse. Specifically, government enforcers must prove intent in order to show that providers engaged in fraud. Most providers certainly understand that if they submit claims for care that was never provided to patients, they had intent and have engaged in fraud. But staff members must also understand that court decisions say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that staff had intent. Other court decisions state that when providers show reckless disregard for a pattern of fraudulent conduct, regulators can show intent necessary to prove fraud. When staff members grasp those crucial standards, it is clear that they must become vigilant to prevent patterns of fraud and abuse. This is necessary in order to prevent government enforcers from concluding that they had intent necessary to prove fraud and/or abuse.
2. Many staff members do not yet understand that every health care provider, regardless of position, is personally responsible for fraud and abuse compliance. It is extremely tempting to think that fraud and abuse compliance is management’s responsibility or the exclusive job of the chief executive officer, the chief operating officer, or the organization’s compliance officer under a Medicare/Medicaid Fraud and Abuse Compliance Program.
On the contrary, the Office of the Inspector General (OIG) of the Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, is quite clear that every provider has personal, individual responsibility for fraud and abuse compliance. The OIG has taken this position because the OIG realizes that the problem of fraud and abuse will never be resolved until every provider takes individual responsibility for it. This point is reinforced by recent charges brought against a home health care agency in Florida called Amitan. Enforcers took action against both upper and lower management and a number of individual staff nurses allegedly involved in billing for visits that they never made, among other fraudulent activities.
When providers understand those two basic points, they are well along the road to active participation in fraud and abuse compliance efforts.
Providers must remember that fraud and abuse compliance is now a permanent part of the health care landscape across the nation.
Compliance is not a fad that will blow over or disappear in a few months. Providers must be prepared to actively work to prevent or correct fraud and abuse for as long as they work in the health care industry.
(To receive a copy of Preventing Fraud and Abuse, a book that provides further information regarding this topic, send a check for $25 for each volume ordered, including shipping and handling, payable to Elizabeth E. Hogue, 15118 Liberty Grove, Burtonsville, MD, 20866. To receive a copy of How to Develop a Fraud and Abuse Compliance Plan, send a check for $55, including shipping and handling, to the above address.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content