Define Healthcare Fraud and Abuse

We often hear about agencies or clinicians committing fraud or partaking in abuse. But what are the clear definitions of fraud and abuse? The new Conditions of Participation (COPs) when followed, will help clear up issues.

Let’s start with fraud…Fraud is to intentionally deceive or falsify information in order to bill Medicare. The ability to commit fraud extends from small providers to large and is not unique to home health. Many types of providers have engaged in blatant fraud including some large hospitals and health systems across the country.

Abuse, however, is somewhat of a moving target and in some cases occurs without honest providers even being aware of such actions. Abuse can range from duplication of services, providing services that are not wanted by the patient, or continuing services when the patient no longer needs such services.

The ability to diagnose abuse by a provider can be much tougher than identifying fraud. Many times, abuse can appear to be well-intentioned services that are provided to a patient with very strong documentation. But when reviewed from the perspective of a surveyor or an auditor, the view can be vastly different.

With the settlement of the Jimmo v. Sebelius case, the gray area between allowing services that allow a patient to remain in the home as long as possible while maintaining a condition versus receiving more acute care can be tough. With the acceptance of maintenance therapy or nursing as allowable under Medicare, the need for strong, clear documentation is essential.

Agencies must continue to invest in their QA programs and take a strong look at reviewing every note, every document, and all records within the chart to ensure compliance. With the mid-point of 2018 approaching, the monetary penalties for not following the new COPs will be disappearing in 2019.

QA is very important for agencies and should not be ignored. The new COPs are going to require consistent and strong programs that will meet regulatory needs, but will also protect the agency from compliance failures. Smaller agencies who aren’t able to meet these needs internally must consider affordable outsourcing methods.

Surveyors are now beginning to understand the COPs and a current report from Medicare indicates that agencies haven’t seen their world come crashing down. However, what Medicare isn’t aware of yet is that most agencies are struggling greatly with some of the requirements and one giant patch isn’t going to make the problem go away.

Providers can learn more about fraud and abuse using CMS’ own educational guide which can be located on the CMS MLN site.  We’ve also partnered with Tortolano & Company to provide HIPPA guidance and operational support for providers across the nation.

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