2019 ALABAMA HEALTHCARE FRAUD SUMMIT BLAKE HENSON H EALTHCARE F RAUD : A P AYER ’ S P ERSPECTIVE An Independent Licensee of the Blue Cross and Blue Shield Association
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2019 ALABAMA HEALTHCARE FRAUD SUMMIT
BLAKE HENSON
HEALTHCARE FRAUD: A PAYER’S PERSPECTIVE
An Independent Licensee of the Blue Cross and Blue Shield Association
OBJECTIVES
Discuss the nature and scope of healthcare fraud
Discuss why and how healthcare fraud occurs
Discuss the federal and state law enforcement environment
Discuss how you can protect your practice
The views and opinions expressed in the following slides are those of the individual
presenter and should not be attributed to Blue Cross Blue Shield of Alabama. These slides are for informational
purposes only.
DISCLAIMER
NETWORK INTEGRITY
Network Integrity (NI) is the name of the Special Investigation Unit and is responsible
for all fraud, waste and abuse activities related to members and providers.
This includes oversight of more than
28 provider networks.
Management
1 RN manager and 1 licensed attorney
8 Investigators
registered nurses, juris doctorates, and certified professional coders
6 of the 8 investigators have their AFHI (Accredited Health Care Fraud Investigator) certification and 3 are also Certified Fraud Examiners (CFE)
All NI associates are 100% dedicated to the efforts to address fraud, waste and abuse
STAFF
An intentional deception or misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized
benefit to him/herself or some other person. It includes any act that
constitutes fraud under applicable federal
or state law.
WHAT IS FRAUD?
Healthcare spending that can
be eliminated without reducing the quality of care such as overuse, underuse, and ineffective use.
WHAT IS WASTE?
Practices by facilities, physicians and other healthcare providers
inconsistent with accepted medical, business and fiscal
practices.
WHAT IS ABUSE?
How does Network Integrity Combat Fraud, Waste and Abuse
• Network Integrity identifies potential fraud, waste and abuse through:
• Prepayment claims reviews
• Retrospective claims reviews
• Service Calls/Inquiries from Members, Vendors and/or Providers
• Data Analysis
• Hotline Calls
• Compliance E-mails
PowerPlugs Templates for PowerPoint Preview 9
Where can fraud and abuse occur?
VULNERABILITIES
Hospitals PhysiciansMembers
Nursing HomesHome
Healthcare
Ambulance Services
Office Staff
Chiropractors Clinics
Brokers and Agents
Durable Medical
EquipmentLaboratories Pharmacies
Drug Manufacturers
Pharmacy Benefit
Managers
Billing Companies
WHY DOES FRAUD OCCUR?
Complex Environment
High Volume Processes
Lots of Potential Revenue
High Trust Relationships
Low Transparency
FRAUD MADE EASY
Internet research
“How to Commit Medicare Fraud
in Six Easy Steps”
Billing for services that were never rendered
Up-coding or billing for more expensive services or procedures than were actually provided
Performing medically unnecessary services – usually diagnostic testing
Misrepresenting cosmetic surgery as medically necessary
COMMON TYPES OF FRAUD
Accepting kickbacks for patient referrals
Falsifying a patient’s diagnosis to justify services and obtain payment
Identity theft
Doctor shopping
Billing for services under an MD’s provider number when they were provided by a NP
COMMON TYPES OF FRAUD
The United States Department of
Health and Human Services-Office of Inspector General
(HHS-OIG) conservatively estimates that
$100 billion is lost to healthcare fraud
each year.
HOW COMMON?
$350 Million in Investigative Support
Predictive Modeling Technology
Enhanced Provider Screening
Increased Federal Sentencing Guidelines
Affordable Care Act
THE FEDERAL INVESTMENT
Healthcare Fraud and Abuse a Top Priority
Bipartisan Focus
Federal Agencies Under Pressure to Show Return
FEDERAL ENVIRONMENT
Government is more engaged with Public and Private Partners
More coordination
Medicare Strike Force –formed March 2007
FEDERAL ENVIRONMENT
Healthcare Fraud Prevention Partnership
• Designed to reduce healthcare fraud and includes the federal government, state officials, private health insurance organizations and other health care anti-fraud groups• Shares information and best practices
• Improves detection
• Prevents payment of fraudulent healthcare billings across public and private payers
• Enables the exchange of data and information amoungstpartners
PowerPlugs Templates for PowerPoint Preview 19
MEDICARE FRAUD STRIKE FORCE
• Multi-agency teams that• Are located in fraud “hot spot” areas
• Uses advanced data analysis to identify high billing levels in healthcare fraud hot spots
• Coordinates national takedowns
Addition of Appalachian Regional Prescription Opioid Strike Force
• October 2018
• Central offices
• Cincinnati / Northern Kentucky
• Nashville
MEDICARE FRAUD STRIKE FORCE
April 2019
• 60 charged defendants
• Included 53 medical professionals (31 Doctors)
• 24,000 patients affected
• 350,000 opioid prescriptions
• 32 million opioid pills
MEDICARE FRAUD STRIKE SUCCESS
Operation Brace Yourself – 130 DME Companies that Submitted Over $1.7 Billion in Claims- April 9, 2019
“…announced charges against 24 people—three were prescribing medical professionals, and the rest were owners or high-ranking officials in medical equipment or telemedicine companies.
…The companies then allegedly paid doctors kickbacks to prescribe unnecessary braces “without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen.”
https://www.fbi.gov/news/stories/billion-dollar-medicare-fraud-bust-040919
“UBIOME”, ubiome.com FBI Raid
https://www.cnbc.com/2019/05/06/ubiome-suspends-clinical-operations-after-fbi-raid.html
Code of Alabama §27-12(a) Insurance Fraud Investigation Unit and Crime Prevention Act –effective August 2012
• Act defines insurance fraud and creates 3 criminal offenses (2 felonies and 1 misdemeanor).
• Imposes a $200 annual fraud unit assessment on all insurers.
• Requires a fraud warning on claim forms, applications, participation agreements, etc.
• Mandates insurers with knowledge or a reasonable belief that fraud is being, will be or has been committed, to file a report with the Department of Insurance.
STATE ENVIRONMENT
FBI-More Interest and Knowledge
• Agents assigned to Healthcare Fraud
• Members of NHCAA
LOCAL ENVIRONMENT
Employer groups demands
Increased request for information
More interest from other agencies
LOCAL ENVIRONMENT
U.S. Attorney
State Attorney Generals
FBI
Department of Labor
CMS Center for Program Integrity
MEDICS / ZPICS
Medicaid Fraud Control Unit
Office of Personnel Management OIG
Postal Inspection Service
HHS OIG
FDA OIG
DEA
Veteran’s Administration OIG
Medical Boards
Department of Insurance
Local Law Enforcement
Private Insurance Industry
LOOKING FOR HEALTHCARE FRAUD
National HealthCare Anti-Fraud Association
(NHCAA)
Regional US Attorney
Workgroup meetings
CMS Regional and National
Workgroup and Information
Sharing meetings
BCBS Association National
Anti-Fraud Department
INFORMATION SHARING
• Mobile physicians involved in pill mill
• Sentenced to 240 and 252 months
• Restitution to Medicare:
$6,282,023
• Restitution to Blue Cross:
$3,649,092.97
• Over 20 cars from their collections seized and auctioned
NOTABLE ALABAMA CASES
I can do more than you!
• Nurse Practitioner billing under a medical doctor’s provider number
• Changed diagnosis codes to received payment
• Found guilty on 2 counts of healthcare fraud
• Found guilty on 1 count of conspiracy
Who did that?
NOTABLE ALABAMA CASES
• Billing for services not rendered
• 1 Pretrial Diversion
• 1 pled guilty
• Court Ordered Restitution of
$350,000
Can you hear me now?
NOTABLE ALABAMA CASES
Maintain complete medical records
Verify patient identity with photo ID
Blue Cross contracts with each individual provider
METHODS FOR SUCCESS
Not Documented Not Done
Documentation needs to be clear.
Documentation needs to support medical necessity
of service provided.
Documentation should include rationale for
testing.
METHODS FOR SUCCESS
Avoid up-coding
Review CPT descriptions
carefully.
High volume of one E/M code is a
red flag.
Must meet documentation requirements
and be medically necessary.
METHODS FOR SUCCESS
Utilizing Electronic Medical Record Software
Templated records.
Prepopulated or carried over data
from one visit to the next.
Select the appropriate
visit level yourself.
Protect electronic signatures.
METHODS FOR SUCCESS
Be aware of your billing practices
• Use qualified people: certified coders
• Have transparent processes
Implement a Compliance Program
• Conduct internal audits
Keep up with published policies
• Subscribe to the Blue Cross List Serve
METHODS FOR SUCCESS
Beware of “revenue generating”
opportunities
Add on services to
existing services
Diagnostic equipment
and services
Coding schemes
Disguised kickbacks
METHODS FOR SUCCESS
Be alert to fraudulent prescription request
Growth of brace and pain cream scam to include genetic testing
Recruitment of physicians by telemedicine companies
EFT related issues
AREAS OF CONCERN
“Scheme of the Day”– Ongoing Investigations
• Add all four ingredients to each warm water foot bath.
• Soak feet 10 minutes/2x day.
• Average cost per foot bath $1,000-$2,000.
Example:Monthly prescription with 10 refills:
• Compounded fungal cream or doxyc/clind as listed below,– Doxycycline- 100 mg capsule #180 - add 3 capsules – Clindamycin 1%- 30ml bottle #60 - add one bottle
(30ml)
• Topical voriconazole 1% eye drops, 200mg, #60 vials - add contents of entire vial
• Flucinolone 0.01% solution #300ml - add 5mls
At the bottom of the prescription in fine print, it reads “the pharmacy is authorized to dispense any of the following medications in lieu of others or as the patient prefers.”
2019 ALABAMA HEALTHCARE FRAUD SUMMIT
BLAKE HENSON
HEALTHCARE FRAUD: A PAYER’S PERSPECTIVE
An Independent Licensee of the Blue Cross and Blue Shield Association
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