Federal officials have a strong message for Medicare health care providers, beneficiaries, and public and private health systems: We will identify, prevent, and prosecute fraudulent billing to the fullest extent of the law, using the newest technology available.
And a further caveat: Those who are aware of fraud and do not report it are also subject to prosecution.
These messages were the theme of an April Health Care Fraud Prevention Summit in Chicago, the seventh in a series of regional summits focusing on fraudulent practices in the Medicare program. The gatherings are part of a fraud-fighting effort initiated by the U.S. Department of Justice (DOJ) and Department of Health and Human Services (HHS) through the Health Care Fraud Prevention and Enforcement Action Team (HEAT).
In partnership with HEAT, Medicare has expanded its Fraud Strike Force operations to include nine fraud hot spots: Baton Rouge, Brooklyn, Chicago, Dallas, Detroit, Houston, Los Angeles, Miami, and Tampa. The Strike Force combines the efforts of the Medicare Criminal Division's Fraud Section, U.S. attorneys' offices, HHS Office of Inspector General, FBI, and other federal, state, and local law enforcement agencies. The Affordable Care Act provides an additional $350 million in funding over the next 10 years.
HHS and DOJ report that during fiscal year 2011, the federal government won or negotiated approximately $2.4 billion in fraud judgments and settlements, with 175 defendants given prison sentences for fraud. None of the cases in the report were for audiology services.
Two cases were specific to speech-language treatment, but did not involve certified speech-language pathologists. In one case, a physical therapist was sentenced to prison for fraud and theft of an SLP's identity; the other case reached a $1.5 million settlement for services provided by an unlicensed practitioner. The report recommends that the Centers for Medicare and Medicaid Services target for further review outpatient therapy claims in high-utilization areas or claims that have questionable billing characteristics.
At the summit, U.S. Attorney General Eric Holder indicated the administration is dedicated to "innovative, proactive, and collaborative" strategies to identify emerging fraud patterns and combat fraud before it begins. The goal is to protect not only the fiscal integrity of the Medicare system, but also the safety of the patients it serves. With collaboration among federal agencies through HEAT, claims data are available simultaneously to all investigators. In addition, a new set of tools allows for real-time analysis of the claims.
Investigators analyze known egregious claims to identify patterns, and compare them to current claims. Providers receive a risk score that identifies whether monitoring is warranted or even whether payments should be suspended until further investigation. Flagged patterns include spikes or dips in billing, significant gaps between dates of service and claim submission, and incongruent services to the same beneficiary. Private insurance also is using this predictive modeling, identifying and reporting fraud and, at times, working with federal investigators.
Kathleen Sebelius, HHS secretary, described a new process that removes providers who are not qualified or no longer exist from provider rolls. Another new third-party enrollment review process includes licensure and background checks.
The Provider Enrollment, Chain, and Ownership System (PECOS) now allows e-signature acceptance for provider enrollment. Providers also will be able to upload other required documentation later this year, making the enrollment process fully digital. The process saves paper and time, and will help prevent provider identity theft.
The HHS whistleblower program is realizing success in its anti-fraud efforts—the Office of General Counsel reports that in fiscal year 2011, $735 million was recovered as a result of whistleblower complaints under the False Claims Act—and HHS encourages more participation from providers and beneficiaries. The Senior Medicare Patrol, a new program that educates beneficiaries about fraud prevention, saw a 50% increase in reported cases in 2011. The American Recovery and Reinvestment Act of 2009 protects whistleblowers from wrongful demotion or discharge (for more information, visit the Office of the Inspector General's website).
A final word of caution from federal officials: A clinician who is aware of fraud in his or her workplace may be subject to individual prosecution. Federal officials stressed that organizations and companies are not the only entities targeted—individual physicians, providers, billers, and even accountants have been investigated, charged, and convicted. Audiologists and speech-language pathologists should practice and bill within Medicare regulations, and report fraudulent situations through the whistleblower program if necessary.
ASHA provides information and resources for clinicians at it's reimbursement webpage. For assistance with individual questions, contact firstname.lastname@example.org.