Business
Office
HCFA's energetic focus on fraud and abuse
is witnessed in the great resources devoted to budget, staff and
press conferences. Consequently, many people - the public in general
and the news media in particular - are growing suspicious of the
healthcare industry's financial dealings.
Those of us responsible for the financial
side of medicine understand that the overwhelming majority of
us have high ethical standards, are honest and diligent in our
professional responsibilities. Unfortunately, the few bad apples
make the headlines and shape public opinion.
As managers, we have a responsibility to
educate all stakeholders and the public on fraud and abuse issues.
A simple review on fraud and abuse seems in order: Fraud is intentional
misrepresentation or deception. It takes place when people know
that an activity is false and could result in some unauthorized
benefit. The most common cases of fraud occur when false statements
or misrepresentations result in entitlement or payment for services.
Abuse takes place when actions occur that
are inconsistent with accepted sound medical practice. Abuse may
directly or indirectly result in unnecessary costs, improper payment
or payment for services that are not necessary or do not meet
professionally recognized standards of care. Abuse also involves
payment for services or goods where there is no legal entitlement
to payment, even if the provider did not knowingly and intentionally
misrepresent facts to obtain the payment.
Following are some benchmark examples:
- Claiming bad debts without first seriously
attempting collection.
- Billing for services not actually provided.
- Billing for non-covered or non-chargeable
services.
- Billing for duplicate payment of services
or supplies.
- Billing for costs not incurred or that
were attributable to non-program activities, other ventures
or personal expenses.
- Reporting incorrect diagnoses or procedures
to optimize payments.
- Not correctly allotting cost on cost
reports.
- Including costs for non-covered services,
supplies or equipment in allowable costs.
Naturally, this is not a comprehensive list.
They are, however, salient examples we can use to explain fraud
and abuse to the public and to non-financial healthcare professionals.
Our educational efforts also will fit neatly into formal compliance
plans.
To close, I also would like to share a
tip with you on building your compliance reference library. Designate
a bookcase, file, etc., as the location for printed copies of
manuals, updates, alerts, general readings, etc. Bookmark web
sites and register with list-serves dealing with compliance issues.
These simple steps will help demonstrate your reasonable efforts
to run a solid compliance program should an audit ever take place.
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