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Among the most talked-about sessions at AMRA's 1985 Annual Meeting was a presentation by the Department of Health and Human Services' Inspector General, Richard Kusserow. JAMRA went behind the scenes to talk with the Inspector General. In this interview, he describes his role in guarding against fraud, waste and abuse in HHS programs, and how his duties affect medical record practitioners.
In accordance with section 205 of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, this annual notice solicits proposals and recommendations for developing new and modifying existing safe harbor provisions under the Federal and State health care programs' antikickback statute, as well as developing new OIG Special Fraud Alerts.
The federal government, armed with more fraud-fighting personnel and bigger budgets, is combining beefed-up kickback laws with the Civil War-era False Claims Act to hit providers with a one-two legal punch. Increasingly, providers are finding their only option is to pay big settlements.
Less than a week after two hospital executives were found guilty of Medicare fraud, hospital groups last week launched an advertising blitz aimed at securing more Medicare money. But that could be a hard sell. Its success will hinge on how much the industry's image has been damaged by the recent convictions in Florida, which came only a few months after convictions in a Kansas City kickback case.
This Article discusses the use of statistical sampling in Medicare and Medicaid fraud and abuse audits. The author reviews cases in which government sampling methodologies have been challenged. Finally, the author describes the various alternatives available for challenging the validity of the statistical sampling used by the government in its audits.
The author analyzes the fraud and abuse track record of his agency in the past years, and discuss why that effort has had beneficial results for the healthcare industry and the federal fisc. The benefits of this enforcement effort flow directly from the specific enforcement actions, and indirectly from the response of others in the industry to the standards set forth in those actions. Mr. Thornton disputes assertions of some in the industry that the enforcement efforts are unfair, arbitrary, or draconian. Rather, they are an appropriate response to a documented problem with which the government is justifiably concerned.
This final rule establishes a new CFR part to implement the statutory requirements of section 1128E of the Social Security Act, as added by section 221(a) of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Section 221(a) of HIPAA specifically directs the Secretary to establish a national health care fraud and abuse data collection program for the reporting and disclosing of certain final adverse actions taken against health care providers, suppliers and practitioners, and to maintain a data base of final adverse actions taken against health care providers, suppliers and practitioners.
This checklist is intended to serve as a starting point from which to untangle the web of laws and regulations affecting e-health transactions, focusing on fraud issues.
After developing new data-mining techniques, the government no longer needs to rely on outdated methods when investigating allegations of hard-to-track healthcare fraud. Today, federal officials, such as U.S. Deputy Attorney General Eric Holder Jr. (left), have an enhanced ability to collect and analyze massive amounts of financial and medical information necessary to successfully prosecute perpetrators of crimes that drain the Medicare program.
A year after the Health Care Financing Administration implemented its controversial transfer payment policy, some hospitals are keeping patients in the hospital longer than necessary in order to receive full DRG payments. That's a risky strategy, say some experts, who warn that inflating length of stay (LOS) solely for financial reasons could provoke a federal fraud investigation. At St. John's Medical Center in Tulsa, OK, case managers haven't attempted to increase LOS in response to the new transfer rule, but they have put the brakes on any additional cuts in LOS for patients in the 10 affected DRGs. Meanwhile, at Elkhart (IN) General Hospital, case managers have made no adjustments, despite losing as much as $200,000 as a result of the transfer rule. Deborah Hale, president of Administrative Consultant Services in Shawnee, OK, suggests that the best approach for case managers eager to offset losses in reimbursement due to the transfer payment policy is to save money by focusing on patients with complicated conditions who traditionally have had longer-than-average lengths of stay.
A May 2000 U.S. Supreme Court decision determining when a Federal bribery statute can be used to fight Medicare fraud has ramifications for healthcare providers. In Fischer v. United States, the Court concluded that healthcare providers that participate in Medicare are considered to receive benefits as set forth in the bribery statute and thus can be prosecuted for fraudulent activities against the government under the statute. The statute mandates a fine, imprisonment for up to 10 years, or both for anyone convicted under it. Provider organizations that receive Medicare payments and business associates of such organizations should be aware that the government may step up its use of the bribery law in prosecuting fraudulent activity. In addition, although the case pertained specifically to healthcare providers that participate in Medicare, providers that do not participate in Medicare may wish to evaluate the advisability of accepting other Federal funding because of the possible reach of the bribery statute.
Many healthcare organizations already have implemented compliance programs for their facilities. However, in light of recent fines and continued scrutiny of such programs by the HHS Office of Inspector General (OIG), healthcare organizations should consider reviewing their current programs against the OIG's relevant model compliance program. Although healthcare organizations are not required to adhere strictly to OIG's model programs, they would benefit from ensuring that their programs meet all the OIG's requirements. The common, minimum elements suggested by the OIG model programs include development and distribution of written compliance policies, the designation of a chief compliance officer to manage the program, the development of a corrective action and enforcement system, and the use of audits to monitor compliance. Using these models as guides, healthcare organizations should be better able to avoid the possibility of fraud and abuse within their organizations.
HealthSouth and its chief executive Richard Scrushy, left, find themselves coping with a public relations nightmare after federal officials last week charged the rehabilitation giant with "massive accounting fraud" and a systematic betrayal of tens of thousands of investors.
A manager of a dental benefits program defines fraud and abuse in the dental context. Such practices may cost as much as four billion dollars annually and have a damaging effect on the trust the profession places in the profession and on the way dentists relate to each other.
When it comes to physician-pharmaceutical manufacturer relationships, the old adage "there's no such thing as a free lunch" has been given much support lately by federal fraud and abuse enforcement authorities. In light of recent enforcement developments and initiatives, physicians must now, more than ever, develop an understanding of the legal boundaries of regulatory and ethical guidelines and carefully evaluate their relationships with pharmaceutical manufacturers for compliance. This article reviews existing regulatory and ethical guidance applicable to physician-pharmaceutical industry relationships, applies that guidance to common interactions between physicians and the industry, and offers tips for maintaining compliance.
The Department of Health and Human Services Office of Inspector General (OIG) has dramatically expanded the scope and frequency of physician fraud and abuse investigations. Further, OIG has increasingly extracted financial settlements and obtained sanctions against physicians. This article identifies seven areas of investigation that will be given highest priority.
Trouble revisited National Century Financial Enterprises last month, when the Securities and Exchange Commission sued four former execs for the accounting fraud that caused the financial firm's collapse in 2002. The investigation worries some, but others, like Kathy Patrick, left, an attorney representing former NCFE investors, says there is "legitimate business to be done in the purchase of healthcare receivables."
The inauguration of the Medicaid program in the mid 1960s ultimately led to the appearance of a wide range of new forms of illegal behavior by physicians. The fact that government authorities, instead of individual patients, were responsible for payments undoubtedly encouraged the large number of violations. A review of the background of sanctioned physicians shows an overrepresentation of psychiatrists and foreign medical graduates as well as minority-group physicians. Interviews with physicians sanctioned for Medicaid fraud and abuse indicated that they routinely placed the blame for their violations on the program, their employees, patients, or others. In particular, they find program guidelines confusing and irrational and insist that they intrude on what ought to be independent medical judgments. The enforcers, for their part, maintain that the convicted physicians are merely rationalizing self-serving and greedy behavior.