About This Guide
As a health care provider, you are responsible to avoid and prevent fraud, waste, and abuse in health care billing. This chapter defines fraud, waste and abuse, and establishes policies for detecting, preventing, and reporting fraud, waste and abuse.
This section is most recently updated as of 11/25/18. It may change without notice. Always check this guide for changes when you have questions.
Seven Core Elements of Compliance
What You Will Learn
Define fraud, waste, and abuse, and give an example of each.
Explain the processes we use at Accend to prevent fraud, waste and abuse.
Explain your responsibilities for preventing fraud, waste and abuse.
Identify the number one best practice for preventing errors an fraud in your time records.
Explain how we will respond if you self-report an error.
The Center for Medicare and Medicaid Services, or CMS has defined requirements for enrolled providers to prevent fraud, waste and abuse. These include the following.
- Written standards of conduct – policies, procedures and other operating guidelines.
- High level oversight – designate a leader responsible for implementing and monitoring the compliance program.
- Effective compliance training – development and implementation of regular and effective training, such as this one.
- Effective lines of communication – ongoing communication and awareness about compliance expectations, including a system to receive, record and respond to compliance questions or reports of potential non‐compliance.
- Disciplinary mechanisms – policies to consistently enforce standards, including enforcement of non‐retaliation standards.
- Monitoring and auditing – systematic checks for compliance with requirements through monitoring and auditing activities.
- Procedures for responding to detected offenses – take the reasonable steps necessary to promptly respond to and prevent further non‐compliance or misconduct – including corrective action as needed.
This guide explains how we will carry out these requirements, and your responsibility in doing the same.
Fraud
- is an intentional act of deception, misrepresentation, or concealment in order to
gain something of value,
- may involve billing for services that were never rendered or billing for services at a higher rate than is actually justified, and
- also occurs when services provided to members are deliberately misrepresented (example duration longer than actually provider), resulting improper payments or overpayments.
Waste
- is over-utilization of services (not caused by criminally negligent actions) and the
misuse of resources
- includes providing/billing for services that are not medically necessary
Abuse
- is the excessive or improper use of health care services or actions that are inconsistent with acceptable business and/or medical practice,
- includes overbilling through negligently inaccurate records, and
- refers to incidents that, although not considered fraudulent, may directly or indirectly cause improper billing.
Examples
The following are examples of fraud, waste and abuse (not a comprehensive list):
-Intentionally or negligently documenting services that were not provided. (Inaccurate start or end times that inflate the duration of a service are included in this definition. Documenting concurrently is the best way to assure accurate records.)
-Providing or authorizing unnecessary or substandard services.
- Substandard services include services that are not producing results as determined by follow-up assessments or the treatment plan review.
- Unnecessary services include services that are not determined medically necessary in the Diagnostic Assessment, other assessments as applicable, and the Treatment Plan. (When someone you serve may need an increase in hours as a result of life circumstances or events, you may request and receive authorization for an increase in hours from your Clinical Supervisor, and modify the plan.)
-Billing for services that do not meet the definition for the service provided, or that are out of scope for the provider.
-Billing for services to an ineligible recipient.
-Falsifying a medical record in order to obtain payment for services.
-Falsifying a medical record (such as an assessment or medical opinion form) to help an individual receive other health care, financial, or social services.
-Inducing participation in a service with gifts, favors, or other compensation. This definition could include offering rides as an inducement to participate in services, when the ride does not fit the definition of acceptable medically necessary travel during in our Documentation Policy.
-Paying for or soliciting payment or other remuneration for referrals.
-Billing separately for services already included in a global fee.
-Billing for services performed by an improperly supervised or unqualified employee, including an employee who has been excluded from providing the service.
-Presenting false credentials in order to qualify to provide services.
-Knowingly allowing fraudulent billing (for example by failing to report knowledge of fraudulent records submitted by others).
Fraud, Waste and Abuse By Recipients of Health Care Services
Recipients of health care services can commit and be convicted of fraud also. Some examples of this are:
- Filing a claim for services or products not received
- Forging or altering receipts
- Obtaining medications or products that are not needed and selling them on the black market
- Providing false information to apply for services
- Doctor shopping to get multiple prescriptions
- Using someone else's insurance coverage for services
Some disclosure of past crimes by people you serve may be protected by therapist-client privilege. Ongoing attempts to defraud, or to use mental health services in furtherance of fraud may not be. If you become aware of someone you serve committing fraud, waste, or abuse, seek guidance from your supervisor on how to counsel and educate the individual about the perils of this behavior, and whether or not it must be reported.
Methods We Use to Prevent Fraud
Compliance Officer
The Billing Manager is the Chief Compliance Officer for preventing fraud, waste and abuse. The duties of the Chief Compliance officer include, but are not limited to:
- Keeping informed and up-to-date as to rules and requirements for billing the services we provide
- Informing and training all staff in changes that affect them
- Assuring that time and billing record authorization and approval processes are in place and working effectively
- Assuring that regular random and scheduled audits are occurring.
- Identifying any patterns, if they exist, of problems or errors in billing that may need to be addressed by staff training or policy/procedures changes, and seeing to it these occur.
Multi-Layer Time Record Approval
A multi-layer progress note/timecard approval process is our primary method for preventing fraudulent or erroneous billing. When we question the veracity of a submitted billing record, or when we question the eligibility or medical necessity of a service, we do not bill for it until it has been fully investigated.
Authorize
Certain records of service, because of the service type, when they exceed a certain typically-expected duration, when there is a potential eligibility problem, and for other reasons, are flagged by built-in business rules in the TabsTM electronic health record. You will be asked to request authorization for these services when you write the progress note.
Approve
As much as possible, we delegate the initial approval of time records to the supervisor most familiar with the provider and persons served.
Accept
After approval, records undergo one more review by the billing team. They review and accept records that have been approved by supervisors. If they find a problem at this level, they may send the records back for editing, or they may mark questionable records as Hold for Billing or Hold for Payroll if they question them, until they can investigate and confirm that they are accurate.
Audits
We also use random and scheduled audits to check the accuracy of records. Read about how and why we do documentation audits here, then return here to continue reading this guide.
Staff Training
All team members will receive training on preventing fraud, waste and abuse upon hire, with annual refresher training.
Your Responsibilities
Your responsibilities in preventing fraud in your own record-keeping are as follows:
- Document concurrently. This is the best possible practice for avoiding inaccurate billing records.
- Stayed trained and informed. Use this guide for keeping up-to-date for how to document the services you provide.
- When you are unsure, ask. If you cannot find the answers you are looking for here, your supervisors will appreciate that you ask. (Send us feedback on the guide as well.)
- Verify what you hear from others. Sometimes, your coworkers may give you inaccurate information about rules and requirements. Check it out.
- Report problems or barriers to compliance with documentation requirements. We are always looking to improve, simplify, and streamline our processes and will appreciate you suggestions for improvement.
- Report problems or mistakes you see that might lead to inaccurate billing. Read more about this in the section that follows.
Committing fraud waste or abuse knowingly, or as a result of a pattern of negligence, may result in immediate termination. Self-reporting errors in a timely manner is welcomed and will not result in disciplinary action.
Reporting
Your Obligation
You have an obligation to report suspected Fraud, Waste and Abuse. When you do, you have our promise of the following:
- You will face no retaliation for reporting, in good faith, suspected fraud, waste or abuse, even if the investigation finds no evidence to support the suspicion.
- You will receive our thanks and appreciation for reporting mistakes you have made that may have resulted in improper billing.
- Your report will be kept strictly confidential.
How to Report
Contact your supervisor, Program Director, the Billing Manager, or the Executive Director. Tell them what you have found. We will take your report confidentially. If it is your mistake you are reporting, we'll help you set the record straight. If it is someone else's mistake, we'll investigate confidentially and correct the problem, if there is one.
We will share with other supervisors as necessary, the information that you provided, but only so much information as is necessary to investigate and correct the problem. Your identity as the reporter will only be shared with other supervisors as necessary to help in the investigation and follow-up.
We will not share with you, if there are any, what disciplinary actions we have taken in response to reports you make about others. This is confidential information and we expect you would appreciate the same confidentiality if it were you.
You may also report fraud directly to the State of Minnesota at the link provided in Resources, below. You will not receive a response from the state when you do so.
How We Respond to Errors
It is never too late to report an error, but sooner is better because it saves work and time for others.
When we find an error in what we have billed for a service we do one of two things: we either refund the payment if it should not have been billed at all, or replace the claim if we have over-billed, or billed incorrectly. Before we can replace a claim, we must take all of the steps necessary to get it returned to the original writer, get it corrected, approved and accepted to make sure our records match what we have billed for the service.
Read more about fraud and abuse laws here.
Resources
See the following for more information on this topic.
This guide is a living document. We want to improve it with your help. Do you have questions? Found a typo? Find yourself wanting more information? Please send us your thoughts about anything in this chapter by tapping on the link below.
May 12, 2023: Minor language clarifications in definitions of fraud, waste, and abuse.
