BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse BHA-FPX4006 Health Care Regulation and Compliance Major Categories of Health Care Fraud and Abuse
Fraud and abuse present significant challenges within the healthcare sector, affecting taxpayers, patients, and various stakeholders. According to the National Healthcare Anti-Fraud Association (n.d.), healthcare expenses reached $3.6 trillion in 2018, with a considerable portion allocated to healthcare insurance claims. Alarmingly, healthcare fraud and abuse are estimated to cost the United States approximately $68 billion annually (Blue Cross Blue Shield, n.d.). The Federal Bureau of Investigation (FBI) leads investigations into fraud and abuse (Health Care Fraud, 2022), while the Office of Inspector General (OIG) oversees governmental efforts to combat fraud, waste, and abuse (Office of Inspector General, n.d.).
It is essential to differentiate between fraud and abuse, as defined by the Centers for Medicare and Medicaid Services (2021). Fraud involves intentional deception for personal or financial gain (Office of Inspector General, 2018), often utilizing sophisticated techniques enabled by technological advancements (Schwayder, 2021). Conversely, abuse refers to the inappropriate or excessive use of resources to deceive or harm, which may lead to financial or non-financial violations (Office of Inspector General, n.d.).
The primary categories of healthcare fraud and abuse include phantom billing, billing for non-existent patients, anti-kickback violations, upcoding service claims, unbundling related services, and providing medically “unnecessary” services (Moseley, 2013).
Five Health Care Fraud and Abuse Laws
Federal healthcare programs such as Medicaid and Medicare are protected by laws designed to combat and prevent fraud and abuse (Centers for Medicare and Medicaid Services, 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 (Centers for Medicare and Medicaid Services, 2021).
The False Claims Act serves as a powerful tool against healthcare fraud, protecting the government from fraudulent claims and imposing significant penalties on violators (Office of Inspector General, 2011). Similarly, the Anti-Kickback Statute criminalizes inducements for referrals, with penalties that may include fines, imprisonment, and exclusion from federal programs (Office of Inspector General, n.d.).
Under the STARK Law, physicians are prohibited from self-referring to designated health services, with violations resulting in fines and program exclusion (Office of Inspector General, n.d.). Additionally, the CMPL authorizes civil monetary penalties for Medicaid and Medicare fraud and abuse, while the Exclusion Statute mandates exclusion from federal healthcare programs for individuals convicted of such offenses (Office of Inspector General, n.d.).
Upcoding and the Law
Upcoding is a common form of healthcare fraud that involves billing for services at a higher reimbursement rate than those actually provided (National Health Care Anti-Fraud Association, n.d.). This deceptive practice violates the False Claims Act and leads to overcharging federal programs (Office of Inspector General, n.d.).
Recent lawsuits have highlighted instances of upcoding, such as the case against Kaiser Permanente, which was accused of submitting inaccurate diagnostic codes to Medicare Advantage to secure 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 requires compliance with federal healthcare laws and regulations, along with accurate coding, billing, and physician documentation (Office of Inspector General, n.d.). Internal monitoring, auditing, and staff training are essential for ensuring compliance and early detection of fraudulent practices (Office of Inspector General, n.d.).
Efforts to combat upcoding and other forms of fraud and abuse are critical to maintaining trust in healthcare providers and protecting federal healthcare programs (Howard, 2020). Reporting suspected fraud and abuse is vital, with resources such as hotlines and governmental websites available for whistleblowers (Office of Inspector General, 2019).
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