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Focusing on Fraud, Waste and Abuse is as Important as Ever!

Focusing on Fraud, Waste and Abuse is as Important as Ever!

The recent budget proposal is taking aim at alleged Fraud, Waste and Abuse in Medicare by reducing spending and increasing pre-authorizations on certain items. The budget proposes over $800 billion in reductions for Medicare! While the proposed budget is not expected to make it out of the House of Representatives, there have been several reports that talk of "Medicare for All" gaining momentum. Regardless of what is on the horizon, there appears to be an increased focus from the government on Fraud, Waste and Abuse in Federal healthcare programs including Medicare and Medicaid.

The Centers for Medicare and Medicaid Services (CMS) defines Fraud as:

  • Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist;
  • Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by Federal healthcare programs; or
  • Making prohibited referrals for certain designated health services.

Waste is defined as the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. Waste is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse is defined as including practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice inconsistent with providing patients with medically necessary services meeting professionally recognized standards. Abuse includes any of the following:

  • Billing for unnecessary medical services.
  • Charging excessively for services or supplies.
  • Misusing codes on a claim, such as upcoding or unbundling codes.

HCP Recommendations

While this list is by no means all-inclusive, it is a good starting point for healthcare organizations to avoid allegations of Fraud, Waste and Abuse. This includes taking the time to ensure accurate information is obtained and documented before submitting to Federal healthcare programs including Medicare and Medicaid, and the following:

  1. Verify you have the right patient and their eligibility.
  2. Determined the services that are being billed are medically necessary.
  3. Ensured the correct diagnostic and CPT codes are being submitted.
  4. You have the right date(s) of services.

From there, anyone who is involved in the claims process must be screened against exclusions lists before submitting a claim. A risk assessment to determine visible risk from a payer perspective and periodic audits should be performed. Be sure that providers and anyone else involved in the medical claims process is trained on the findings of the risk assessment and audits. This will go a long way to protecting your organization.

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