We have been hearing much about Fraud and Abuse in the news lately and are aware the government has their eyes on the Anesthesia profession. As providers of medical care we must be very familiar with these concepts.

Fraud is an intentional action that results in a benefit to the perpetrator. The intention must be present for an action to be found to be a fraudulent activity. In healthcare that is usually found with intentionally submitting claims for reimbursement for services that weren’t rendered or were not given in the manner claimed. A violation of the anti-kickback statute that results in reimbursement to the group can result in a false claims allegation by the OIG.

Other actions can lead to allegations of false claims such as retention of overpayments, billing for services not provided or medically unnecessary, or up coding a claim, which uses a higher code than that which indicates the service rendered. An example of up coding is using a code with a higher amount of base units than that performed. Unbundling services breaks apart elements into separate items of a service that is reimbursed as a bundle. There have been cases where an anesthesiologist unbundled provision of oxygen and basic monitoring from basic anesthesia care to bill for them separately.

Examples of fraud that show intent to defraud include: documenting a service that did not occur, upgrading the physical status, submitting documentation for reimbursement that you know is not correct and creating false documentation to support a higher level of service.

The term abuse means practices that are not consistent with medical, business or financial standards that result in waste of funds for reimbursement.  It is usually used in association with fraud.
Some examples of abuse are billing noncovered services as covered services, reporting duplicate charges on a claim, charging excessively for services, and improper billing that results in payment by a government program when another payer is responsible.

Anesthesia Compliance Consultants will assist your organization to develop a comprehensive Compliance Plan that covers the seven components.  The plan will be created to be consistent with the needs of the anesthesia practice. The plan will satisfy federal and state guidelines, laws and regulations.  If you have a compliance plan in place, we will review your current plan and revise it to assure that it contains all the steps.  This effectively will help reduce your risk of fraud and offer the most protection for your organization.  

Our team consists of professionals with extensive backgrounds in healthcare law and anesthesia practice. We have been in the field of Anesthesia Compliance since 2002 and have assisted numerous organizations with their compliance programs.