 |
Health Care Fraud and AbuseObtaining or the attempt to obtain payments for services by dishonest means is fraud. Altering patient records is fraudulent behavior. Other areas considered fraudulent behavior include: misrepresenting a patient’s diagnosis to justify a service; altering claims to obtain a higher reimbursement; unbundling charges to game the system for services that a carrier may group together; completing certificates of medical necessity for equipment as a means to gain referrals; or billing a patient and the carrier for the same service and keeping both payments.
Medical or billing practices inconsistent with acceptable standards may be seen as abusive behavior. Areas to consider as potentially abusive include: incorrect billing to Medicare; increasing charges to Medicare patients and not to others; submitting claims for non-medically necessary services; and overutilization of services for minor medical conditions.
Operation Restore Trust (ORT), a program initiated by HCFA to combat fraud and abuse in medical billing includes physicians in New York State. ORT enlists not only the Inspector General, but also the Department of Justice, and other state and local agencies.
As previously noted in “Compass” Medicare beneficiaries have also been asked to actively participate in antifraud programs. This has become an issue for some senior citizens seeking health care. Many physicians surveyed reported increased concern over the past three years that senior citizens may misunderstand services provided and claims submitted. This increased concern has encouraged many office practices to implement billing compliance programs.
|