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Fraud & Medicare Compliance
Thomas N. Shorter, Esq., FACHE
1
PSOW 28th Annual Workshop
September 23, 2015
Tundra Lodge Hot...
Overview
• Legal Framework
−Governmental Oversight
−Other groups to know
−Laws to Know
• Recent Fraud Activity
• Complianc...
Legal Framework - Governmental Oversight
Federal
OIG – Office of Inspector General
DHS - U.S. Department of Health & Human...
Additional Groups to Know
ZPICs – Zone Program Integrity Contractors
Primary goal – to identify cases of suspected fraud,
...
Additional Groups to Know cont.
RACs – Recovery Audit Contractors
To identify and correct Medicare improper
payments throu...
Laws to Know
6
Anti-kickback Statute
False Claims Act
Laws to Know - Anti-kickback Statute
42 U.S.C. § 1320a-7b.
Unlawful to: knowingly and willfully, solicit or
receive any re...
Laws to Know - Anti-kickback Statute
Unlawful to: Knowingly and willfully, offer to pay
any remuneration (directly or indi...
Law to Know – Anti-kickback Statute
3 necessary elements:
• Intentional Act
• Direct and Indirect Payment of Remuneration
...
Laws to Know - Anti-kickback Statute
Statutory Exceptions and Safe Harbors
• Discounts;
• Employees;
• Group Purchasing Or...
What is Remuneration?
An extremely broad scope, whether in case or in kind,
and whether made directly or indirectly, inclu...
Laws to Know - False Claims Act
31 U.S.C. §§ 3729-3733 – “Lincoln Law”
Prohibits a person from “knowingly” submitting clai...
Laws to Know – False Claims Act cont.
Key elements
• False Claims
• Intent
• Materiality
• Causation
13
Laws to Know – False Claims Act cont.
Key Healthcare Theories
• Upcoding/billing for Services not Rendered
• False Certifi...
Recent Fraud Activity
Florida - 9 hospitals agreed to a $6.2M
settlement for allegations of billing Medicare for
unnecessa...
Recent Fraud Activity cont.
Connecticut – 2 ambulance services will
pay $595,000 to resolve inappropriately
billing Medica...
Compliance Program Guidance for
Ambulance Suppliers
Federal Register, Vol. 28, No. 56,
March 24, 2003, 14245-14255.
Basic ...
Compliance Program
• Basic Elements (continued)
• Respond Appropriately to Detected Misconduct.
• Develop effective lines ...
The presentation and materials are intended to provide information on legal issues and should not be construed as legal ad...
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Fraud and Medicare Compliance - PSOW 2015

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Fraud and Medicare Compliance - PSOW 2015

  1. 1. Fraud & Medicare Compliance Thomas N. Shorter, Esq., FACHE 1 PSOW 28th Annual Workshop September 23, 2015 Tundra Lodge Hotel & Convention Center Green Bay, WI
  2. 2. Overview • Legal Framework −Governmental Oversight −Other groups to know −Laws to Know • Recent Fraud Activity • Compliance Program Guidance 2
  3. 3. Legal Framework - Governmental Oversight Federal OIG – Office of Inspector General DHS - U.S. Department of Health & Human Services DOJ – Department of Justice CMS – Center of Medicare/Medicaid Services State AG - Wisconsin Attorney General’s Office DHS - Wisconsin Department of Health Services OIG - Office of Inspector General 3
  4. 4. Additional Groups to Know ZPICs – Zone Program Integrity Contractors Primary goal – to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not appropriately paid out and that any mistaken payments are recouped. ZONE 3 – Cahaba Safeguard Administrators −Operational April 24, 2012 −IL, IN, KY, MI, MN, OH and WI 4
  5. 5. Additional Groups to Know cont. RACs – Recovery Audit Contractors To identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. 5
  6. 6. Laws to Know 6 Anti-kickback Statute False Claims Act
  7. 7. Laws to Know - Anti-kickback Statute 42 U.S.C. § 1320a-7b. Unlawful to: knowingly and willfully, solicit or receive any remuneration (directly or indirectly, overtly or covertly, in cash or in kind). In return for referring any item or service reimbursable by federal health care programs, or purchasing, leasing, ordering or arranging for (or recommending any of the same) any good, facility or service reimbursable by federal health care programs. 7
  8. 8. Laws to Know - Anti-kickback Statute Unlawful to: Knowingly and willfully, offer to pay any remuneration (directly or indirectly, overtly or covertly, in cash or kind). To induce: Referring for any item or service reimbursable by federal health care programs, or purchasing, leasing, ordering or arranging for (or recommending any of the same) any good, facility or service reimbursable by federal health care programs. 8
  9. 9. Law to Know – Anti-kickback Statute 3 necessary elements: • Intentional Act • Direct and Indirect Payment of Remuneration • To Induce the Referral of Patients or Business 9
  10. 10. Laws to Know - Anti-kickback Statute Statutory Exceptions and Safe Harbors • Discounts; • Employees; • Group Purchasing Organizations; • Sale of a practice; • Referral Services; • Warranties; • Investment Interests; • Space Rental; • Equipment Rental; • Personal Services and Management Contracts; and • Waiver of Deductibles and Coinsurance. 10
  11. 11. What is Remuneration? An extremely broad scope, whether in case or in kind, and whether made directly or indirectly, including: − Kickbacks; − Bribes; − Rebates; − Gifts; − Above or below market rent or lease payments; − Discounts; − Furnishing of supplies, services or equipment either free, above or below market; − Above or below market credit arrangements; and − Waiver of payment due. 11
  12. 12. Laws to Know - False Claims Act 31 U.S.C. §§ 3729-3733 – “Lincoln Law” Prohibits a person from “knowingly” submitting claims or making a false record or statement in order to secure payment of a false or fraudulent claim by the federal government. A person: has actual knowledge of the information, acts in deliberate ignorance of the truth or falsity of the information, and acts in reckless disregard of the truth or falsity of the information. 12
  13. 13. Laws to Know – False Claims Act cont. Key elements • False Claims • Intent • Materiality • Causation 13
  14. 14. Laws to Know – False Claims Act cont. Key Healthcare Theories • Upcoding/billing for Services not Rendered • False Certification of Compliance with Regulations • Quality of Care/Worthless Services • Improper Retention of Overpayments • “Causing” submission of False Claims Does not cover false tax returns. 14
  15. 15. Recent Fraud Activity Florida - 9 hospitals agreed to a $6.2M settlement for allegations of billing Medicare for unnecessary ambulance transports. California – 5 ambulance companies agreed to settle kickback allegations for $11.5 M. Pennsylvania – ambulance company developed a Medicare fraud scheme of $2 million in inappropriate bills. 15
  16. 16. Recent Fraud Activity cont. Connecticut – 2 ambulance services will pay $595,000 to resolve inappropriately billing Medicare and Medicaid. Wisconsin – MTM recently audited by DHS after receiving complaints by Medicaid and BadgerCare Plus members throughout the State. 16
  17. 17. Compliance Program Guidance for Ambulance Suppliers Federal Register, Vol. 28, No. 56, March 24, 2003, 14245-14255. Basic Elements: • Development of Compliance Program. • Designate a Compliance Officer and Committee. • Conduct effective training and education. • Develop Internal Monitoring and Reviews. 17
  18. 18. Compliance Program • Basic Elements (continued) • Respond Appropriately to Detected Misconduct. • Develop effective lines of communication. • Conduct internal auditing and monitoring. • Enforce standards through well-publicized disciplinary guidelines. • Respond promptly to detecting offenses and take appropriate corrective action. 18
  19. 19. The presentation and materials are intended to provide information on legal issues and should not be construed as legal advice. In addition, attendance at a Godfrey & Kahn, S.C. presentation does not create an attorney-client relationship. Please consult the speaker if you have any questions concerning the information discussed during this seminar. OFFICES IN MILWAUKEE, MADISON, WAUKESHA, GREEN BAY AND APPLETON, WISCONSIN AND WASHINGTON, D.C. Thank You Thomas N. Shorter, Esq., FACHE One East Main Street, Suite 500 Madison, WI 53703 608.284.2239, tshorter@gklaw.com 19

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