The main tools for detection of fraud and abuse were traditionally through whistleblowers who took information of a suspicious practice to the government. This tool is still used, but electronic audits and monitoring are now playing a large role in fraud detection. Usually, with either type of investigation you won’t know you are under investigation until the government unveils its case against you. For some groups this is after many years of investigation and evidence collection. With electronic means to review your claims for up to the last 10 years the risks are very high for anesthesia providers
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.