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This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur without the permission of Tulane University. Tulane University retains all intellectual property interests associated with the presentation. Tulane University makes no claim, promise, or guarantee of any kind about the accuracy, completeness, or adequacy of the content of the presentation and expressly disclaims liability for errors and omissions in such content.

Fraud and abuse avoiding pitfalls

Tulane University Medical Group

Fraud and Abuse

Avoiding Pitfalls

Compliance Education and Training

One Compliance Credit earned for viewing presentation and completing quiz

TUMG Compliance

Read before proceeding
Read Before Proceeding

Physicians and Staff may earn one compliance credit by viewing this slide show, completing the assessment, and faxing the assessment to the

University Privacy and Contracting Office: 504-988-7777

This presentation may be viewed for compliance credit only once in a fiscal year

(July 1 - June 30).

To check how many compliance credits you have and to see which training sessions you have completed, contact the University Privacy and Contracting Office at



It is the policy of TUMG to provide healthcare services that are in compliance with all state and federal laws governing its operations and consistent with the highest standards of business and professional ethics. Education for all TUMG physicians is an essential step in ensuring the ongoing success of compliance efforts.

Purpose of presentation
Purpose of Presentation are in compliance with all state and federal laws governing its operations and consistent with the highest standards of business and professional ethics. Education for all TUMG physicians is an essential step in ensuring the ongoing success of compliance efforts.

  • To provide physicians and staff with

    • Definitions and examples of fraud and abuse

    • An overview of resources to assist providers in appropriately coding services rendered

Why does cms center for medicaid and medicare services put such an emphasis on fraud abuse
Why does CMS (Center for Medicaid and Medicare Services) put such an emphasis on Fraud & Abuse?

  • Complexity of the program

  • Expense

Complexity of the program
COMPLEXITY OF THE PROGRAM such an emphasis on Fraud & Abuse?

  • The expansion of the Medicare and Medicaid programs (including the prescription drug option) and the complexity of the programs make it difficult to adequately monitor.

  • Physicians are expected to “Know the Rules” and properly apply them to their billing.


Medicare spends approx. $40 billion per year for medical services

In recent years, billing and reimbursement for some services has greatly increased

The OIG Work Plan often targets those medical services where reimbursement exceeds budget projections

The Medicare Program is under increasing pressure to remain solvent as “baby boomers” move into Medicare-eligible age range.

The prescription benefit will add more cost to the program


But it s not just medicare that investigates and prosecutes billing fraud and abuse
But it’s not just Medicare that investigates and prosecutes billing fraud and abuse…

  • A common billing myth is that providers should only be concerned with bills submitted to Medicare.

  • All payors, whether governmental or commercial, have billing guidelines that must be followed.

A note about la medicaid
A note about LA Medicaid… prosecutes billing fraud and abuse…

  • Louisiana Medicaid has billing guidelines that are different from those of Medicare and/or commercial payors.

  • It is important that providers understand and correctly apply the appropriate billing guidelines.

Physicians are responsible for their billing
Physicians are responsible prosecutes billing fraud and abuse…for their billing

  • Physicians are responsible for understanding and appropriately applying billing guidelines for the services they provide.

  • Providers should take an interest in their billing and take care to avoid billing practices that could be construed as either fraud or abuse.

Some sobering facts
Some Sobering Facts prosecutes billing fraud and abuse…

  • OIG exclusion database through August 2006 (checked 9/13/06) lists 813 businesses/ private citizens in Louisiana excluded due to fraudulent practices (up from 742 in 7/2005)

    • (source: OIG exclusion database)

Some sobering facts oig 2004 annual report

During 2004, the prosecutes billing fraud and abuse…Federal Government won or negotiated approximately $605 million in judgments and settlements.

U.S. Attorneys’ Offices opened 1,002 new criminal health care fraud investigations involving 1,685 potential defendants.

A total of 459 defendants were convicted for health care fraud-related crimes during the year.

The Department of Justice opened 868 new civil health care fraud investigations, and had 1,362 open civil health care fraud investigations

Some Sobering Facts: OIG 2004 Annual Report

Source: Annual Report of the Attorney General and the Secretary Detailing Expenditures and Revenues Under the Health Care Fraud and Abuse Control Program For Fiscal Year 2003


It is a federal crime to defraud prosecutes billing fraud and abuse…

the U.S. Government or any of

its programs and can result in

imprisonment, fine or both.

Fraud and abuse penalties
Fraud and Abuse Penalties prosecutes billing fraud and abuse…

  • Civil Monetary Penalties (CMP)

  • Criminal Sanctions (jail, exclusion from the Medicare/ Medicaid program)

What entities investigate and prosecute fraud and abuse
What entities investigate and prosecute Fraud and Abuse? prosecutes billing fraud and abuse…

  • Department of Health and Human Services (DHHS)

  • Department of Justice (DOJ)

  • Office of the Inspector General (OIG)

  • FBI

  • Medicaid Fraud Units

What laws acts establish the framework for investigation prosecution
What laws/acts establish the framework for investigation & prosecution?

  • HIPAA (Health Insurance Portability and Accountability Act (Title II)

  • Federal False Claims Act

  • Stark Legislation (Phases I and II)

  • “Anti-kickback statute” (part of the Medicare/Medicaid statute)

  • Mail Fraud

  • Sarbanes-Oxley

Definition of fraud
Definition of Fraud prosecution?

  • Intentional. Deliberate deception.

    • Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.

    • Source: Medicare Resident and New Physician Guide, page 124

Examples of fraud
Examples of Fraud prosecution?

  • Billing for services not furnished and/or supplies that were not provided

  • Offering incentives to Medicare patients that are not offered to non-Medicare patients (e.g., routinely waiving or discounting the Medicare deductible and/or co-insurance amounts)

Examples of fraud1
Examples of Fraud prosecution?

  • Offering, soliciting, or accepting bribes, kickbacks, or discounts for referral of patients or orders of services or items

  • Falsifying information on applications, medical records, billing statements, and/or cost reports or any statement filed with the government

  • Misrepresenting excluded services as medically necessary by using inappropriate procedure or diagnosis codes

Definition of abuse
Definition of Abuse prosecution?

  • Unintentional. Occasional.

  • Practices that either directly or indirectly result in unnecessary costs to the Medicare program.

    • Abuse may appear similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully and intentionally.

      • Source: Medicare Resident & New Physician Guide, page 124

Abuse can escalate into fraud
Abuse can escalate into Fraud prosecution?

  • Repeated billing errors that point to a BILLING PATTERN may be construed as a fraudulent billing practice

  • Occasional/unintentional misinterpretation of billing guidelines may be considered abuse; repeated, routine billing practices that do not comply with billing guidelines may be construed as fraudulent

Examples of abuse
Examples of Abuse: prosecution?

  • Providing medically unnecessary services

  • Providing services that do not meet professionally recognized standards.

  • Violating the participating physician, supplier agreement with Medicare or Medicaid

  • Charging in excess for services or supplies

    • Source: Medicare Resident and New Physician Guide, page 125

Avoiding pitfalls
Avoiding pitfalls prosecution?


    • All providers should be familiar with the billing guidelines for Medicare, Medicaid and Commercial payors

Avoiding pitfalls1
Avoiding pitfalls prosecution?

  • Ignorance of billing guidelines is not considered a defense against a fraud or abuse allegation.

  • The contractual agreements between providers and payors clearly state the provider’s responsibility to understand and appropriately apply billing rules.

Recent fraud cases
Recent Fraud Cases prosecution?

  • December 2005 –

    • … a dentist was sentenced to 63 months in prison and ordered to pay $827,000 in restitution and a $20,000 fine; he was found guilty in a jury trial on charges of mail fraud and health care fraud. The dentist performed unnecessary dental procedures on patients and billed for services not performed, or not performed as indicated.

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/05/1205.html

Recent fraud cases1
Recent Fraud Cases prosecution?

  • March 2006 –

    • … a dermatologist was sentenced to 20 years in prison and ordered to pay $888,888 in restitution for unlawfully distributing prescription narcotic drugs and health care fraud… a jury found that the dermatologist’s conspiracy to distribute prescription narcotics resulted in the death of a patient. The patient, who died from an overdose of Dilaudid, saw the dermatologist approximately 24 times each month… the patient allowed the dermatologist to submit the fraudulent bills, in exchange for prescriptions for controlled substances and monthly cash payments of $700.

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/06/0306.html

Recent fraud cases2

February 2006 – Virginia prosecution?

… a podiatrist was sentenced to one year and one day in prison for mail fraud. The podiatrist billed for procedures performed at a surgery center when, in fact, the services performed were routine, and performed in the office. The address of the surgery center was actually a mailbox rental business located next to his office. Through his billing scheme, the podiatrist was reimbursed for facility-related charges such as pre-op and post-op rooms.

Recent Fraud Cases

Source: OIG website http://oig.hhs.gov/fraud/enforcement/criminal/06/0206.html

The more you know resources for providers

The More You Know... prosecution?Resources for Providers

TUMG Compliance

Cms sources e m services
CMS Sources - E/M Services prosecution?

  • Medicare Teaching Physician Rule

    • http://www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf

  • Medicare 1995 documentation guidelines

    • http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf

  • Medicare 1997 documentation guidelines

    • http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

U s government website http www cms hhs gov lamedicare website http www lamedicare com
U.S. Government Website: prosecution?http://www.cms.hhs.govLAMedicare Website: http://www.lamedicare.com/

Medicare Resources

Medicare resources
Medicare Resources prosecution?

  • You may also be interested in:

    • http://www.trispan.com/factsheets/FraudAlert.pdf

      • A concise, one-page reference that lists examples of fraud and abuse.

    • http://www.medicare.gov/FraudAbuse/Tips.asp

      • This reference sheet targets Medicare recipients. A list of questionable activities are listed, and recipients are told “You should be suspicious if the provider tells you that…”


Know who to contact prosecution?:

  • M. Reina, Senior Director, TUMG Business Services mreina@tulane.edu

  • Compliance Reporting Hotline: 504-988-5142


End of Presentation prosecution?

To Earn Compliance Credit:

Complete and Sign the “Fraud and Abuse” Coding Quiz

Fax to: 504-988-7777