BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Student Name

Capella University

BHA-FPX4006 Health Care Regulation and Compliance

Prof. Name

Date

Major Categories of Health Care Fraud and Abuse

Healthcare fraud and abuse present significant challenges within the healthcare domain, impacting various stakeholders such as taxpayers, patients, and related entities. The National Healthcare Anti-Fraud Association (NHCAA) reported that in 2018, healthcare expenses soared to 3.6 trillion dollars, with a considerable portion designated for healthcare insurance claims. Alarmingly, health care fraud and abuse are estimated to incur a staggering annual cost of 68 billion dollars in the United States (Blue Cross Blue Shield, n.d.). Spearheading investigations into fraud and abuse is the Federal Bureau of Investigation (FBI) (Health Care Fraud, 2022), while governmental oversight, combating fraud, waste, and abuse, falls under the purview of the Office of Inspector General (OIG) (Office of Inspector General, n.d.).

It is imperative to differentiate between fraud and abuse, as outlined by the Centers for Medicare and Medicaid Services (CMS, 2021). Fraud involves intentional deception for personal or financial gain (OIG, 2018), often leveraging sophisticated techniques facilitated by technological advancements (Schwayder, 2021). In contrast, abuse entails the inappropriate or excessive utilization of resources to deceive or harm, potentially leading to financial or non-financial violations (OIG, n.d.).

The primary categories of healthcare fraud and abuse encompass phantom billing, billing for nonexistent patients, anti-kickback violations, upcoding service claims, unbundling related services, and provision of medically unnecessary services (Moseley, 2013).

Five Health Care Fraud and Abuse Laws

Federal healthcare programs such as Medicaid and Medicare are fortified by laws aimed at combating and preventing fraud and abuse (CMS, 2021). These laws include the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (STARK Law), the Civil Monetary Penalties Law (CMPL), and the Exclusion Statute (CMS, 2021).

The False Claims Act serves as a robust tool against healthcare fraud, shielding the government from fraudulent claims and imposing substantial penalties on violators (OIG, 2011). Similarly, the Anti-Kickback Statute criminalizes inducements for referrals, with penalties including fines, imprisonment, and program exclusion (OIG, n.d.).

Physicians are prohibited from self-referral to designated health services under the STARK Law, which mandates fines and program exclusion for violations (OIG, n.d.). Moreover, the CMPL authorizes civil monetary penalties for Medicaid and Medicare fraud and abuse, while the Exclusion Statute mandates exclusion from federal healthcare programs for convicted individuals (OIG, n.d.).

Upcoding and the Law

Upcoding, a prevalent form of healthcare fraud, involves billing for higher-reimbursing services than those rendered (NHCAA, n.d.). This deceptive practice violates the False Claims Act and results in overcharging federal programs (OIG, n.d.).

Recent lawsuits highlight instances of upcoding, such as the case against Kaiser Permanente, accused of submitting inaccurate code diagnoses to Medicare Advantage for increased reimbursements (Payne, 2021). Similarly, CareWell Urgent Care Center settled FCA claims for overbilling Medicare and Medicaid for unnecessary medical services (PR Newswire, 2019).

Identifying and Addressing Upcoding in Health Care

Preventing upcoding necessitates compliance with federal healthcare laws and regulations, along with accurate coding, billing, and physician documentation (OIG, n.d.). Internal monitoring, auditing, and staff training are vital for ensuring compliance and early detection of fraudulent practices (OIG, n.d.).

Efforts to combat upcoding and other forms of fraud and abuse are essential to preserving trust in healthcare providers and safeguarding federal healthcare programs (Howard, 2020). Reporting suspected fraud and abuse is imperative, with resources such as hotlines and governmental websites available for whistleblowers (OIG, 2019).

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

References

All About E/M Codes. (2022, June 11). Retrieved October 17, 2022, from https://www.aapc.com/evaluation-management/em-coding.aspx

Blue Cross/Blue Shield. (n.d.). Fraud Statistics. https://www.bcbsm.com/health-care-fraud/fraudstatistics.html

Centers for Medicare and Medicaid Services. (2021). Medicare fraud & abuse: Prevent, detect, report. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf

Department of Justice. (2019). Three physicians and five marketers charged for violation to federal anti-kickback statue. The United States Attorney’s Office, Northern District of Oklahoma. https://www.justice.gov/usao-ndok/pr/three-physicians-and-five-marketers-chargedviolations-federal-anti-kickback-statutes

Health Care Fraud. (2022). Federal Bureau of Investigation. Retrieved October 16, 2022, from https://www.fbi.gov/how-we-can-help-you/safety-resources/scams-and-safety/commonscams-and-crimes/health-care-fraud

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Schwayder, J. (2021). Health care fraud exposed: The penalties of deception can be much worse than medical negligence. Contemporary OB/GYN, 66(7), 30–32. https://web-s-ebscohostcom.library.capella.edu/ehost/detail/detail?vid=0&sid=3a270469-bfee-42f9-b8ce7c526323c9aa%40redis&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=151458139&db=ccm