Question

Dr. Able has asked you to be in charge of a new compliance team for the prevention of fraud and abuse practices. What types of employees would you ask to be part of the team? The agenda of the first meeting will be to define fraud and abuse and provide examples of each. Once you have compiled a list, discuss solutions and proper ways to handle these situations. Define for your team the penalties for fraudulent activities.

Answer 1

COMPLIANCE means following a rule or order and being an incharge for a compliance team means to make sure that the staff do their work correctly and work should be according to laws..

Team...

This team is called HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM. (HEAT)

I think should consists of chief compliance officer ,doctors, nurses, billing staff, auditing staff and even fourth class because they also must be educated about abuse

FRAUD :

"Any deliberate or dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person commiting the act or someone else who is similarly not entitled to the benefit"

It means that fraud is intentional act for unauthorized benefit

Examples:

• Billing for items that are not sold
• Duplicate claims
• Misrepresenting the person or services.. For eg: introducing themselves as superior authority or telling the patients that a particular service which they are receiving has better options too like forcing them to shift to a single room from semi private room and telling them that they would receive better services there
• Falsification of information in medical records
• Billing for services that are not provided eg:oxygen administration, mobilisation, water beds etc
• Billing for items and services that are not medically necessary like water bed charges for a stable patient
• Seeking payments for procedures which are performed along with other procedures on same date of service for example when a unconscious patient is advised to undergo CT contrast scan, it is obvious that we need to insert nasogastric tube and IV cannula... But charging for this separately is a fraud
• Upcoding :seeking increased payment for services correctly billed at lower rate
• Forging or selling prescription drugs

ABUSE:

PRACTICE THAT IS INCONSISTENT WITH ACCEPTED SOUND FISCAL, BUSINESS OR MEDICAL PRACTICES THAT RESUKTS IN UNNECESSARY COST AND REIMBURSEMENT FOR SERVICES THAT FAIL TO MEET PROFESSIONALLY RECOGNIZED STANDARDS

it means abuse or neglect is any action or failure to act which causes in reasonable suffering, misery or harm to the patient.

Fraud is always intentional but abuse may or may not be intentional

Same examples that are covered under fraud are applicable here also. Other examples are

• ACTIVE ABUSE: pushing, slapping, kicking, punching, pinching...this is an intentional act
• MISUSE OF RESTRAINTS: using restraints is against federal regulation. They should be used only for medical purposes or for patients safety and that too for a short time
• PHYSICAL NEGLECT : NOT providing sufficient food, clothes or sanitary environment etc this can be because of staff shortage or may be intentional
• Abuse can be even on the health care staff like doctors, nurses etc by patient's family etc

Fraud and abuse can be either from provider side or from patients side

Fraud from patient side

• Altering health care bills or forging them to get health care reimbursement
• Filing claims for medical procedures or prescriptions or both that they did not receive
• Using someone else's insurance card
• Allowing someone else to use your insurance card

SOLUTION FOR OVERCOMING FRAUD AND ABUSE

• Have a proper Id card for all the staff with their proper designation... Check I'd cards of the staff before they start rendering their services.. If biometry is available in the hospital that would be best saver
• Have colour coded uniforms for staff. This helps the patient to remember and give us some information in case of any abuse or fraud
• PRESCRIPTION FRAUDS.... If there is a report that prescription pads are missing or fraudulent prescription is found... Take it seriously and take immediate action.. Prescription pads should be available only with authorized persons and it should not be accessible to others
• BILLING FRAUDS: perform sudden audits. Ensure accuracy when submitting bills or claims
• TRAINING AND EDUCATION:Force importance of documentation and coding

Education training sessions should emphasize the accuracy of coding to prevent undercoding

Training should not focus on just undercoding or overcoding but it should focus on valid documentation and patient safety

Focus on the amount of time spent to examine patient

Train employees about documentation process

Explain them to have a good communication with each other and with other sections also to avoid mistakes

Ask them to clarify with the concerned person if they have any doubts

• IMPLEMENTATION OF COMPUTER ASSISTED CODING :Using electronic techniques reduces the fraud incidence.

Use of computer software that automatically generates a set of medical codes for review, validation and use based on clinical documentation of health care practices helps us to reduce the mistakes from coding side

• FEDERAL ENFORCEMENT OF FRAUD AND ABUSE MONITORING :explain them about federal false claim act and punishments they receive if they are found to involve in the act
• DATA MODELLING AND DATA MINING:many people are involved in fraud and abuse

This method helps to detect both consumer and provider fraud.data mining has 3 components

1.data curation...appropriate data standards and methods are introduced

2.an algorithmic component... Selection of methods base Fn on their pros and cons

3.implementation process

All these if used correctly, helps to reduce fraud

• ABUSE:educate the staff that abuse is not correct in health care and they they will be punished seriously if found

PUNISHMENT FOR FRAUDULENCE I

AWARENESS IS NEEDED IN STAFF REGARDING THE PUNISHMENT FOR FRAUD AND ABUSE

• lengthy jail
• Fine
• Probation
• Loss of professional license
• Restitution for any amount that the defendant profited
• In case of abuse against healthcare staff a jail of nearly 3to 10years and monetary fine also

With all these we can reduce the fraud rates in health care settings...