1. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Pearson's Comprehensive Medical Assisting Administrative and Clinical Competencies Second Edition CHAPTERCHAPTER CHAPTER 19 Medical Coding Lesson 3: Insurance Fraud

2. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter.

3. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Defining Fraud An intentional representation that an individual makes but knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to him or herself or some other person.

4. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Tips for Preventing Insurance Fraud Look at your Medicaid bill carefully to make sure that Medicaid has been billed for medical services or goods that you really received. Check to see that the date of service is correct. DO NOT ask your doctor or other health care provider for medical care that you do not need.

5. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Tips for Preventing Insurance Fraud DO NOT give your Medicaid card number to anyone except your doctor, clinic, hospital or other health care provider. DO NOT let anyone borrow your Medicaid card. Treat your card the way you treat your credit card.

6. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Tips for Preventing Insurance Fraud DO NOT sign your name to a blank form. Ask for a copy of everything you sign. Keep the copy for your records. DO NOT share your Medicaid records or other medical information with anyone except your doctor, clinic, hospital, or other health care provider.

7. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Tips for Preventing Insurance Fraud If you are offered free tests or screenings in exchange for your Medicaid card number, be suspicious. Be careful about accepting Medicaid services when you are told they will be free of charge. DO NOT give your Medicaid card number to anyone or do business with door-to- door or telephone sales people who tell you that services or medical equipment are free.

8. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Tips for Preventing Insurance Fraud Give your Medicaid identification card only to those who have provided you with medical services. Never allow a medical provider to bill for services rendered without contacting you first. If anyone claims they know how to make Medicaid pay for health care services or goods that Medicaid usually does not pay for, you should avoid them.

9. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking 1.Visit the Centers for Medicare and Medicaid Services (CMS) website for more information.

10. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Violators of Insurance Fraud Physician or other practitioner Hospital or other institutional provider Clinical laboratory or other supplier Employee of any provider Billing service Beneficiary Medicare carrier employee Person in a position to file a claim for Medicare benefits

11. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Most Common Forms of Fraud in Medicare Billing insurance companies for services not furnished Misrepresenting the diagnosis to justify payment Soliciting, offering, or receiving a kickback Billing for separate services that are usually bundled in a single procedure code

12. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Most Common Forms of Fraud in Medicare Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment “Upcoding” which is billing for a service at a higher level than was actually provided

13. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Indicators of Fraud The test is free; the doctor only needs your Medicare number for his records Medicare wants you to have the item or service The medical office knows how to get Medicare to pay for it The more tests the patient takes, the cheaper they are The equipment or service is free, it won’t cost the patient anything

14. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Critical Thinking Question 1.What might be some indicators to customers that fraud may be occurring in their physician’s practice?

15. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Suspicious Office Practices that Should Alert Consumers Routinely waiving copayments without checking on the ability to pay Advertising “free” consultations to Medicare beneficiaries Claiming they represent Medicare Using pressure or scare tactics to sell high priced medical services or diagnostic tests

16. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Suspicious Office Practices that Should Alert Consumers Billing Medicare for services the patient does not recall receiving Using telemarketing and door-to-door selling as marketing tools

17. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Information Requested by the National Fraud Hotline Name of the Medicaid client Client's Medicaid card number Name of the doctor, hospital, or other health care provider Date of service Amount of money that Medicaid approved and/or paid Description of the acts that you suspect involve fraud or abuse relating to your allegation

18. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Agencies to Report Fraud Program Integrity contact in the agency that oversees your state's Medicaid program Office of Inspector General's (OIG) National Fraud Hotline (1-800-HHS- TIPS).

19. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Benefits of Having a Compliance Plan Office is at a lower risk for liability Demonstrates to the physician, fraud investigators, and insurance carriers that the medical office is making every effort to locate and correct errors Gives the staff members of the office a process of locating, correcting, and preventing practices that are illegal

20. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Basic Components of a Compliance Plan Conducting periodic audits of billing and coding practices Developing written standards and procedures for compliance Training and educating staff members on procedures Investigating violations and disclosing incidents to appropriate government agencies Discussing in staff meetings how to avoid erroneous or fraudulent conduct

21. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Code Linkage The services and procedures that are provided must link with the diagnosis Example: Diagnosis - Upper respiratory distress and Procedure - Chest X-ray

22. Copyright ©2011 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e Beaman Fleming-McPhillips Routh Gohsman Reagan Questions?