Healthcare Reform and the New Opportunities for the Ethically Challenged May 21, 2009 Rebecca S. Busch, RN, MBA, CFE, CCM, CBM, FIALCP, FHFMA CEO, Medical Business Associates 580 Oakmont Lane, Westmont IL 60559 www.mbanews.com info@mbanews.com 630.789.9000 Webinar Agenda • Fraud: key initiative in healthcare reform • Global Perspective on Fraud & Fraud Concepts in Healthcare • Profiling Fraud • Review Critical Schemes • Review Latest Fraud Issues • Who Gets Hurt? • Trigger Points
Polling Question #1 • How many people in the audience: – Work for hospitals? – Work for insurance companies – Work for a government agency or law enforcement – Are not in healthcare and just want to learn more about the topic? Polling Question #2 • Are you are actively involved in healthcare fraud related work? – Yes – No
Polling Question #3 • Have you ever worked directly with a individual consumer that was a fraud victim? – Yes – No Polling Question #4 • Have you ever been a victim of healthcare fraud in any form? – Yes – No
FRAUD – Technical Definition • Misrepresentation of a material fact consisting of a false representation, concealment or non-disclosure; • Knowledge of the falsity • Intent to deceive and induce reliance; • Justifiable and actual reliance on the misrepresentation; and • Resulting damages. FRAUD – On the front line • “Things” or “Events” that hurt people • Affecting ones person, home, family, assets, and community • Resulting in disability, financial devastation, loss of loved ones, and death • Leaving a person with a loss of faith, hope, trust, and sense of identity
WHY AN ISSUE? • 2 TRILLION DOLLAR Industry • OIG ROI ON AUDITS/INVESTIGATION $17 TO $1 • Estimated that $60 billion annually goes to fraud Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf OIG areas of concern • Payments for unallowable services • Improper services not rendered • Improper claims submissions • Medicare reimbursement rates are too high for certain services. • Payments for inadequately documented services • Manipulation of billing systems • Inaccurate wage data • Manipulative gaming through discharge or transfer of patients to facilities for financial versus clinical reason. • Unreasonable and not medically necessary services Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf
OIG Identified Vulnerabilities • DME suppliers circumventing enrollment and billing controls • High levels of improper Medicare payment for certain types of DME, prosthetics, orthotics, and supplies (DMEPOS); • Inappropriate reimbursement rate for certain DMEPOS. Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf 5 Principals of Effective Anti Fraud Activity 1. Scrutinize individuals and entities that want to participate as providers and suppliers prior to their enrollment in health care programs. 2. Establish payment methodologies that are reasonable and responsive to change in the market place. 3. Assist health care providers and supplier in adopting practices that promote compliance with program requirements, including quality and safety standards. 4. Vigilantly monitor the programs for evidence of fraud, waste, and abuse. 5. Respond swiftly to detected frauds, impose sufficient punishment to deter others, and promptly remedy program vulnerabilities. Source: http://www.oig.hhs.gov/testimony/docs/2009/4-22-09HomelandSecurity.pdf
Global Perspective • Primary Healthcare Continuum • Secondary Healthcare Continuum • Information Continuum • Consequence Continuum • Transparency Continuum Primary Health Care Continuum (“P-HCC”): Clinical, Service, Product, and Financial Integration E-Health Data Driven Decisions ����� �����,� �����'������ ��������� %�������� �����,� �����'������ ������ ������ &������� ���'���� $������� &�������������� ��������� (�'�������� �������� ������� ���'����,�� ���'����,�� �����%�������� ������������ -�������� -�������� ���������� ���'������ �������������%���� ������������ �������������%���� �������� ������� �������������� �������������� ������� (�'�� ���������������� $������������� ���������������� $������� -�������������� -�������������� %������ )���������"� ��������� * ��������������������� ��������������������� ��������������������� ��������������������� ���������� )��������� ���������������������������������������� ����������� ���������������������������������������� "+��* ���������������������������������������������� %������ ���������������������������������������������� ������������������������������������� ������������������������������������� ��������������� �����!����������"����#������#����������� ��������������� �����!����������"����#������#����������� Segmented, Fragmented, Insulated, Lacks Service & Price Transparency
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