Wiki Concerned about Fraud

[AdamlShoop]

I have yet to work anywhere as a coder, but i have heard of a few stories of physicians or hospitals trying to get more money by coding incorrectly. I am an honest person, and I absolutely loathe the idea of anyone being cheated! I am wondering, how easy is it for businesses to lie and cheat in the coding aspect of things and get away with it??

 

[btadlock1]

I have yet to work anywhere as a coder, but i have heard of a few stories of physicians or hospitals trying to get more money by coding incorrectly. I am an honest person, and I absolutely loathe the idea of anyone being cheated! I am wondering, how easy is it for businesses to lie and cheat in the coding aspect of things and get away with it??

If somebody really wanted to, it probably wouldn't be all that hard. More often, though, honest mistakes or ignorance of the rules leads to improper payments, than willful deception. The real test of character in a practice, is how they react, when overpayments due to improper coding are discovered. An honest mistake can quickly devolve into fraud, if it's handled the wrong way. I don't think you have to worry too much, though. Most people just try to do the best they can. Just stay current on the rules, and educate others when needed. Hope that helps!

 

[AdamlShoop]

Thank you

Thank you Brandi for always being so willing to help.

 

[swebco]

With advancing data mining efforts individuals that deliberately game the system will have a much harder time doing so. That being said the Director of Investigation has pointed out that criminal enerprises are entering the Medicare/Medicaid programs at an alarming rate. These criminals have learned that they have about 90 days from the granting of a DME license to file as many claims as possible, using a purchased list of beneficiary numbers, and get as much money as possible before the review mechanisms even catch on that they are doing anything wrong.

Others have invented even more intricate frauds, like the ones in south Florida involving infusion clinics.

The problem, as was pointed out, is that these individuals can close down in an area that is receiving intense review and open up anywhere else in the country, leading to 'hot spots' of fraud following the same schemes.

THe bad news is, providers who engage in legitimate business, in some cases, have figured out that the OIG may have bigger fish to fry and their little one off and two off miscoding of services to obtain higher reimbursement so they may go unnoticed.

Part of our job is not only to refuse to participate, but report on those providers that do this. I know, no one wants to be a rat, but the criminal enterprises only account for a fraction of the fraud. THe one off's and two off's represent the majority. Let me be clear, as well, this is not about the provider who makes legitimate mistakes, this is about the provider who deliberately miscodes for financial gain.

I always look on money taken in this manner as money that belongs to me, came out of my pocket through my Medicare and other taxes.

SO fight the good fight and stay on the right side of the regulations. I am personally so risk adverse I don't even like going near the gray areas without good incentive and legal guidance.

 

[btadlock1]

With advancing data mining efforts individuals that deliberately game the system will have a much harder time doing so. That being said the Director of Investigation has pointed out that criminal enerprises are entering the Medicare/Medicaid programs at an alarming rate. These criminals have learned that they have about 90 days from the granting of a DME license to file as many claims as possible, using a purchased list of beneficiary numbers, and get as much money as possible before the review mechanisms even catch on that they are doing anything wrong.

Others have invented even more intricate frauds, like the ones in south Florida involving infusion clinics.

The problem, as was pointed out, is that these individuals can close down in an area that is receiving intense review and open up anywhere else in the country, leading to 'hot spots' of fraud following the same schemes.

THe bad news is, providers who engage in legitimate business, in some cases, have figured out that the OIG may have bigger fish to fry and their little one off and two off miscoding of services to obtain higher reimbursement so they may go unnoticed.

Part of our job is not only to refuse to participate, but report on those providers that do this. I know, no one wants to be a rat, but the criminal enterprises only account for a fraction of the fraud. THe one off's and two off's represent the majority. Let me be clear, as well, this is not about the provider who makes legitimate mistakes, this is about the provider who deliberately miscodes for financial gain.

I always look on money taken in this manner as money that belongs to me, came out of my pocket through my Medicare and other taxes.

SO fight the good fight and stay on the right side of the regulations. I am personally so risk adverse I don't even like going near the gray areas without good incentive and legal guidance.

Well said!

 

[kevbshields]

I'm afraid I don't share the same rosy outlook as some of our peer posters. From the time I spent on the payer side and continued involvement I have with those types of assignments, abuse is pretty common.

In many instances of abuse, providers are not staffing their offices with certified coders, hospitals develop internal policies that permit them to "DRG creep" by utilizing off-limit source documents and making assumptions on their coding. Too, billing departments and A/R are more concerned about "getting the billed paid" than whether or not that bill is correct. This makes it extremely difficult for payers. Daily they receive claims from providers who have no internal structure or audit that monitors the accuracy of their E/M levels, much less the more complex services. What is placed on the charge ticket goes to the bill.

I'm sorry, there is no wonder government payers have increased their scrutiny of claims. There are some serious coding and billing quality issues out there and it seems the only way to motivate providers and organizations is by using every resource available to identify errors, kick those claims back and recoup any overpaid or improperly paid monies. Complacency, laxity and ignorance are the drivers of most of this. Greed and criminal activity are another discussion.

 

[btadlock1]

I'm afraid I don't share the same rosy outlook as some of our peer posters. From the time I spent on the payer side and continued involvement I have with those types of assignments, abuse is pretty common.

In many instances of abuse, providers are not staffing their offices with certified coders, hospitals develop internal policies that permit them to "DRG creep" by utilizing off-limit source documents and making assumptions on their coding. Too, billing departments and A/R are more concerned about "getting the billed paid" than whether or not that bill is correct. This makes it extremely difficult for payers. Daily they receive claims from providers who have no internal structure or audit that monitors the accuracy of their E/M levels, much less the more complex services. What is placed on the charge ticket goes to the bill.

I'm sorry, there is no wonder government payers have increased their scrutiny of claims. There are some serious coding and billing quality issues out there and it seems the only way to motivate providers and organizations is by using every resource available to identify errors, kick those claims back and recoup any overpaid or improperly paid monies. Complacency, laxity and ignorance are the drivers of most of this. Greed and criminal activity are another discussion.

You bring up an interesting subject - I have a theory, that sometime in the next decade, it will be a requirement for coders to be certified, either by individual payers through contractual obligations, or on a state or federal level. Healthcare costs are coming under more intense scrutiny every day, and the microscope will only get magnified further once PPACA comes under fire. Just my conjecture, though!