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FRAUD AND ABUSE IN CODING

Fariha Jivanee
Date: 10/19/13

DEFINITION OF FRAUD
Intentional. Deliberate deception.

DEFINITION OF ABUSE
Unintentional. Occasional.

EXAMPLES OF FRAUD
Billing for services not provided. Accepting bribes or discounts for referral of patients or orders of

services or items
Falsifying information on applications, medical records and/or

billing statements.
Misrepresenting excluded services as medically necessary by

using inappropriate procedure or diagnosis codes.

EXAMPLES OF ABUSE
Providing medically unnecessary services Providing services that do not recognized standards. Violating the participating physician, supplier agreement with

Medicare or Medicaid
Charging in excess for services or supplies

RECENT FRAUD CASES


October 2008

In October, Medicare suspended millions of dollars in payments to the top 10 home healthcare agencies in Miami after discovering that since 2001 Medicare's payments for home healthcare in Dade County had grown by a whopping 1,750 percent - to $1.3 billion - while the pool of people over age 65 diagnosed with diabetes had grown by just 30 percent. To put it another way, Medicare's payments for home healthcare in Miami-Dade grew at a pace 13 times the national rate. Medicare officials say that right now about one in every 15 Medicare dollars spent on home healthcare in the U.S. is spent in Miami-Dade County alone.

RECENT FRAUD CASES


August 2008

CoxHealth has agreed to pay more than $60 million to settle a False Claims Act lawsuit in which the company was charged with overbilling Medicare. CoxHealth actually stole more money than they are being required to return to the U.S. Government because as federal agents began calculating the damages, it soon became clear Cox could not pay without going under.

LAWS AND GOVERNING AGENCIES


A number of government agencies oversee compliance and fraud, waste and abuse related to Medicare Advantage and Prescription Drug programs. These agencies include:
Office of Inspector General Defense Criminal Investigative Services Department of Justice Federal Bureau of Investigations United States Attorneys Office

REPORTING VIOLATIONS
Office of Inspector General

Phone: 1-800-HHS-TIPS (800-447-8477)


Fax: 1-800-223-2164 Email: HHSTips@oig.hhs.gov Mail: Office of the Inspector General

HHS TIPS Hotline


PO Box 23489 S Washington, DC 20026

REFERENCES
http://www.fraudusa.com/healthcare-

fraud-cases.php
http://www.medicare.gov/FraudAbuse/

HowToReport.asp

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