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Fraud, Waste & Abuse
    in Health Care
Definitions
Definitions

Terms have legal
  significance
Definitions
  Fraud
Definitions
         Fraud
Action: Knowingly making a
 false statement or claim
Definitions
          Fraud
Action: Knowingly making a
 false statement or claim
Result: Funding unauthorized
           benefit
Definitions
         Fraud
Example: Filing a claim on
   services that were
    never performed
Definitions
  Waste
Definitions
          Waste
Action: Misuse or overuse of
         resources
Definitions
          Waste
Action: Misuse or overuse of
         resources
Result: Funding unnecessary
           costs
Definitions
         Waste
Example: Writing high-cost
  prescriptions over less
    expensive generic
      prescriptions
Definitions
  Abuse
Definitions
          Abuse
Action: Improper use of info
     or documentation
Definitions
          Abuse
Action: Improper use of info
     or documentation
Result: Funding for personal
 gain without evidence of
       criminal intent
Definitions
         Abuse
Example: 99215 E/M for one
  hour when the visit was
  actually only 15 minutes
How prevalent is
fraud & abuse in
U.S. health care?
In 2011, $98 billion
  was lost due to
Medicare/Medicaid
   fraud & abuse
What is the
government doing
   to prevent
 fraud & abuse?
Title XIX to SSA


1965
Anti-Fraud & Abuse Amendments

Title XIX to SSA


1965    1977
False Claims Act

   Anti-Fraud & Abuse Amendments

Title XIX to SSA


1965    1977       1986
HIPAA


           False Claims Act

   Anti-Fraud & Abuse Amendments

Title XIX to SSA


1965    1977       1986   1996
HIPAA


           False Claims Act

   Anti-Fraud & Abuse Amendments

Title XIX to SSA                 Deficit Reduction Act

1965    1977       1986   1996      2005
HIPAA

                                      Healthcare Fraud
           False Claims Act       Prevention & Enforcement
                                     Action Team (HEAT)

   Anti-Fraud & Abuse Amendments

Title XIX to SSA                 Deficit Reduction Act

1965    1977       1986   1996      2005      2009
Meaningful Use
  American
 Recovery &
Reinvestment
 Act/ HITECH


2009
Affordable Care Act

Meaningful Use
  American
 Recovery &
Reinvestment
 Act/ HITECH


2009             2010
Affordable Care Act

Meaningful Use
  American
 Recovery &             Center for Program
Reinvestment                 Integrity
 Act/ HITECH


2009             2010
Healthcare Reform
                                    OIG Releases
           Affordable Care Act     Report on E/Ms
                                      & EHRs
Meaningful Use
  American
 Recovery &             Center for Program
Reinvestment                 Integrity
 Act/ HITECH


2009             2010                   2012
Want to learn more about
fraud & abuse in health care?

Visit successehs.com/archived-webinars
 to view the free, complete webinar +
  slides, “EHRs, RAC Audits & Coding –
     What Providers Need to Know”
Fraud, Waste & Abuse in Health Care
Fraud, Waste & Abuse in Health Care

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Fraud, Waste & Abuse in Health Care

  • 1. Fraud, Waste & Abuse in Health Care
  • 5. Definitions Fraud Action: Knowingly making a false statement or claim
  • 6. Definitions Fraud Action: Knowingly making a false statement or claim Result: Funding unauthorized benefit
  • 7. Definitions Fraud Example: Filing a claim on services that were never performed
  • 9. Definitions Waste Action: Misuse or overuse of resources
  • 10. Definitions Waste Action: Misuse or overuse of resources Result: Funding unnecessary costs
  • 11. Definitions Waste Example: Writing high-cost prescriptions over less expensive generic prescriptions
  • 13. Definitions Abuse Action: Improper use of info or documentation
  • 14. Definitions Abuse Action: Improper use of info or documentation Result: Funding for personal gain without evidence of criminal intent
  • 15. Definitions Abuse Example: 99215 E/M for one hour when the visit was actually only 15 minutes
  • 16. How prevalent is fraud & abuse in U.S. health care?
  • 17. In 2011, $98 billion was lost due to Medicare/Medicaid fraud & abuse
  • 18. What is the government doing to prevent fraud & abuse?
  • 19. Title XIX to SSA 1965
  • 20. Anti-Fraud & Abuse Amendments Title XIX to SSA 1965 1977
  • 21. False Claims Act Anti-Fraud & Abuse Amendments Title XIX to SSA 1965 1977 1986
  • 22. HIPAA False Claims Act Anti-Fraud & Abuse Amendments Title XIX to SSA 1965 1977 1986 1996
  • 23. HIPAA False Claims Act Anti-Fraud & Abuse Amendments Title XIX to SSA Deficit Reduction Act 1965 1977 1986 1996 2005
  • 24. HIPAA Healthcare Fraud False Claims Act Prevention & Enforcement Action Team (HEAT) Anti-Fraud & Abuse Amendments Title XIX to SSA Deficit Reduction Act 1965 1977 1986 1996 2005 2009
  • 25. Meaningful Use American Recovery & Reinvestment Act/ HITECH 2009
  • 26. Affordable Care Act Meaningful Use American Recovery & Reinvestment Act/ HITECH 2009 2010
  • 27. Affordable Care Act Meaningful Use American Recovery & Center for Program Reinvestment Integrity Act/ HITECH 2009 2010
  • 28. Healthcare Reform OIG Releases Affordable Care Act Report on E/Ms & EHRs Meaningful Use American Recovery & Center for Program Reinvestment Integrity Act/ HITECH 2009 2010 2012
  • 29. Want to learn more about fraud & abuse in health care? Visit successehs.com/archived-webinars to view the free, complete webinar + slides, “EHRs, RAC Audits & Coding – What Providers Need to Know”