Our Compliance Tip

We have heard much about Fraud, Waste 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. 

The Fraud, Waste and Abuse program has become very important and it is mandatory for healthcare professionals including Anesthesia Providers to understand the concepts.

Why It Is Important

Most important of all, the reason for this new required program is to help practitioners become aware of the significant problem we have today in terms of Medicare Fraud and Abuse.  Medicare abuse costs taxpayers billions of dollars and puts beneficiary’s health and welfare at risk.  In 2011 the US lost 3-10 % or $82-$272 billion annually due to healthcare fraud and abuse.

Fraud, and Intentional Action

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 this may occur when services are not rendered or given in a matter claimed and they are intentionally billed.   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 we normally bill together.  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

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. 

What is Abuse

Primarily the term abuse means practices that are not consistent with medical, business or financial standards that result in waste of funds for reimbursement.  The government often links this with fraud.  

As an example of abuse is billing non-covered 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.

Most important of all CMS requires all providers to know how to combat fraud and abuse.  Providers must also learn how to keep their organizations from engaging in abusive practices that hurt the Medicare program.