Fraud & Abuse
What is Insurance Fraud?
Did you know that every insurance claim form includes a statement that certifies the information submitted on the claim is accurate? When erroneous or misleading information is included on a claim form, or when submitting a claim with erroneous or fabricated information, a healthcare professional is potentially committing insurance fraud. The National Health Care Anti-Fraud Association provides the following examples of fraud:
- Billing for services that were never provided
- Billing for services that were more expensive than those actually provided
- Performing unnecessary services
- Misrepresenting treatments that were non-covered as medically necessary
- Providing false diagnoses
- Unbundling procedures so that they appear separate
- Overbilling a patient his or her co-pay
- Waiving a patient’s co-pay while overbilling the insurance company
- Accepting kickbacks
Combatting Fraud
Insurance companies have joined forces through the National Health Care Anti-Fraud Association to develop sophisticated computer systems to detect suspicious claim patterns. The Federal Bureau of Investigation (FBI) and the Office of the Inspector General (OIG) each have assigned hundreds of special agents to health-fraud projects.
But claims software and special agents can’t solve the problem by themselves. Electrodiagnostic (EDX) providers have firsthand knowledge of how the billing and coding process for EDX services should work. AANEM encourages members to familiarize themselves with the avenues that can be taken to report suspected fraud or abuse.
Where to Report Fraud
If you think you have discovered an insurance fraud scheme, the agencies listed below will allow you to safely, easily, and, in most cases, anonymously report the fraud. Download Reporting Fraud (PDF)
State Insurance Fraud Bureaus
You should report any physician or practice committing fraud or abuse to the state insurance fraud bureau in the state(s) in which the fraud or abuse occurred.
Other Agencies
Protecting Your Practice
One of the areas of continuous focus in the Office of Inspector General (OIG) work plan is EDX testing. Government auditors evaluate the extent to which Medicare utilization rates for EDX services differ by provider, specialty, diagnosis, and geographic area.
Simple coding errors are unlikely to capture the attention of the OIG. However, attributing billing errors to a lack of knowledge offers no protection in an audit or a criminal investigation. A practice that consistently codes incorrectly, including billing
for services not provided, is courting disaster.
Every physician has a responsibility to ensure their documentation is accurate, appropriately coded and billed correctly, even if the coding and billing is delegated to office staff.
News Story: Seven High-Profile NCS Fraud Cases
10/15/2013
Since May 2012, the OIG has leveled penalties of almost $13 million in restitution/fines, along with jail terms equal to 70 years behind bars, to providers who have been found guilty of fraudulently billing nerve conduction tests. Read More
UPDATE: On June 18, 2015, a nationwide sweep by the Medicare Fraud Strike Force resulted in charges against 243 medical professionals for fraudulent Medicare billing totaling approximately $712 million. The sweep included 17 districts across the nation and included a wide range of alleged fraud schemes. One scheme involved a licensed pain management physician in Tampa, FL who billed for nerve conduction studies and other services that were allegedly never performed. Medicare paid the physician over $1 million for these services. For more information, please see the U.S. Department of Justice’s website: http://www.justice.gov/opa/pr/national-medicare-fraud-takedown-results-charges-against-243-individuals-approximately-712.
Since May 2012, the OIG has leveled penalties of almost $13 million in restitution/fines, along with jail terms equal to 70 years behind bars, to providers who have been found guilty of fraudulently billing nerve conduction tests. Read More
UPDATE: On June 18, 2015, a nationwide sweep by the Medicare Fraud Strike Force resulted in charges against 243 medical professionals for fraudulent Medicare billing totaling approximately $712 million. The sweep included 17 districts across the nation and included a wide range of alleged fraud schemes. One scheme involved a licensed pain management physician in Tampa, FL who billed for nerve conduction studies and other services that were allegedly never performed. Medicare paid the physician over $1 million for these services. For more information, please see the U.S. Department of Justice’s website: http://www.justice.gov/opa/pr/national-medicare-fraud-takedown-results-charges-against-243-individuals-approximately-712.
Why is Quality EDX Testing Important?
The Solution: Mandate EDX Laboratory Standards
The American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) established the Electrodiagnostic (EDX) Laboratory Accreditation Program to ensure that providers meet the proper standards of care for quality electrodiagnostic medical care. The accreditation process reviews the laboratory’s:- Personnel: ensuring proper education, supervision and experience of all staff per AANEM’s Who Is Qualified to Practice EDX Medicine;
- Facility: verifying safety policies and standards, appropriateness of equipment, existence of quality improvement programs and proper record retention policies;
- Patient Reports: warranting accurate and correct reporting of EDX examinations through peer-review, ensuring compliance with AANEM’s Reporting Results of Needle EMG and Nerve Conduction Studies and evidence-based guidelines.
Reporting Scope of Practice Issues
If you believe a provider is practicing outside of his or her scope, you should inform your state’s Board of Medicine.
- Utilize or reference the sample letters: Physician or Non-Physician.
- Send a copy of the report with the patient information excluded. Explain if the diagnosis is inaccurate or if the provider is acting outside his or her scope.
- Send a copy of your correspondence to the AANEM to document unqualified providers in your state.
Be prepared to give as much information as possible, including:
- Full details of the suspected inappropriate activities including dates and names
- Organizations involved, including phone numbers and addresses (if relevant)
- Insurance company or companies that were defrauded or did the defrauding (if relevant)
- Amount of money you think was lost
- Documents, other written material, and any other information you think might be helpful