fraud, waste & abuse in health care

Fraud, Waste & Abuse in Health Care

Definitions

Definitions

Terms have legal significance

Fraud

Definitions

Fraud

Definitions

Action: Knowingly making a false statement or claim

Fraud

Definitions

Action: Knowingly making a false statement or claim

Result: Funding unauthorized benefit

Fraud

Definitions

Example: Filing a claim on services that were never performed

Waste

Definitions

Waste

Definitions

Action: Misuse or overuse of resources

Waste

Definitions

Action: Misuse or overuse of resources

Result: Funding unnecessary costs

Waste

Definitions

Example: Writing high-cost prescriptions over less

expensive generic prescriptions

Abuse

Definitions

Abuse

Definitions

Action: Improper use of info or documentation

Abuse

Definitions

Action: Improper use of infoor documentation

Result: Funding for personal gain without evidence of

criminal intent

Abuse

Definitions

Example: 99215 E/M for one hour when the visit was actually only 15 minutes

How prevalent is fraud & abuse inU.S. health care?

In 2011, $98 billion was lost due to

Medicare/Medicaid fraud & abuse

What is the government doing

to prevent fraud & abuse?

1965

Title XIX to SSA

1965 1977

Anti-Fraud & Abuse Amendments

Title XIX to SSA

1965 1977

Anti-Fraud & Abuse Amendments

Title XIX to SSA

1986

False Claims Act

1965 1977

Anti-Fraud & Abuse Amendments

Title XIX to SSA

1986

False Claims Act

1996

HIPAA

1965 1977

Anti-Fraud & Abuse Amendments

Title XIX to SSA

1986

False Claims Act

1996 2005

Deficit Reduction Act

HIPAA

1965 1977

Anti-Fraud & Abuse Amendments

Title XIX to SSA

1986

False Claims Act

1996

HIPAA

2005

Deficit Reduction Act

2009

Healthcare Fraud Prevention & Enforcement

Action Team (HEAT)

2009

American Recovery &

Reinvestment Act/ HITECH

Meaningful Use

2009

American Recovery &

Reinvestment Act/ HITECH

Meaningful Use

2010

Affordable Care Act

2009

American Recovery &

Reinvestment Act/ HITECH

Meaningful Use

2010

Affordable Care Act

Center for Program Integrity

2009

American Recovery &

Reinvestment Act/ HITECH

Meaningful Use

2010

Affordable Care Act

Center for Program Integrity

2012

OIG Releases Report on E/Ms

& EHRs

Healthcare Reform

Want to learn more about fraud & abuse in health care?

Visit successehs.com/archived-webinars to view the free, complete webinar + slides, “EHRs, RAC Audits & Coding –

What Providers Need to Know”