Every year, millions of dollars are improperly spent because of fraud waste, and abuse. This can be halted and prevented if the process of detect, correct, and prevent, is followed. This process is required by The Social Security Act, as well as CMS regulations. It is stated that those whom of which supply medicare and medicaid services, are required to have an effective compliance program of which includes measures to prevent, detect, and correct Medicare non-compliance. There must also be implemented measures to prevent, detect, and correct fraud, waste, and abuse. These steps and measures must be provided via effective training for employees, managers, and directors, as well as their first tier, downstream, and related entities. (42 C.F.R. 422.503 and 42 C.F.R 423.504)
An effective compliance program can be implemented via in-class settings, online courses, and "one on one" training. If created correctly, an effective program would consist of steps as to how to detect, correct, and prevent. It must also contain the 7 core compliance program requirements.
The first step in stopping fraud waste and abuse, is prevention. Being the most crucial step in halting fraud, is to go to the most vulnerable portion of information and ensure it's safety. The most common types of fraud an abuse in the medicaid program include medical identity and theft, unnecessary billing, upcoding, unbundling, and beneficiary fraud.
Medical identity theft, being the most common, involves the misuse of a person’s medical identity to wrongfully obtain health care goods,
services, or funds. More specifically, medical identity theft has been defined as “the appropriation or misuse of a
patient’s or [provider’s] unique medical identifying information to obtain or bill public or private payers for fraudulent
medical goods or services.” Unique medical identifying information for physicians includes the National Provider
Identifier, Tax Identification Number, U.S. Drug Enforcement Administration number, and State medical license
number. Physician medical identifiers are used for such things as identifying the physician of record on claims and for
tracking purposes. Stolen physician identifiers may be used to fill fraudulent prescriptions, refer patients for unnecessary
additional services or supplies, or bill for services that were never provided.
An excellent example of Medical Identity was seen when the ringleader of a criminal group in the Bronx stole prescription pads from doctors and hospitals in the
New York City area. Between 2009 and 2011 she used the pads to forge more than 250 prescriptions for
painkillers. By using stolen Medicaid cards, she was able to bill the prescriptions to the Medicaid program
for a total of more than $200,000. She received two consecutive 4 to 8 year sentences in prison. Thus, one tip for prevention is that health care professionals should keep their prescription pads in a
The second most abused form of fraud is the billing for products or services that are not covered or medically needed. The Federal Medicaid statute authorizes payment for items and services that are included in each State’s approved plan. The included items and services vary from State to State. Only those items and services included in the relevant
State’s plan are authorized. Even if an item or service is authorized, it is still not covered under Medicaid unless it is
also medically necessary. This can be easily prevented by constant review and analysis of your Medicaid approved plan, this will stop you and your organization from purchase of non-covered goods and or services. If excessive purchases are made using medicaid that are not covered by the approved plan, the purchasing party can receive an extreme amount of jail time, as well as fines. This was exemplified when an ambulance service owner in Texas was sentenced to 15 years for billing Medicare and Medicaid for
transporting patients by ambulance to dialysis appointments even though the medical condition of the
patients did not qualify for that level of transportation.
Although it may sound like a complex network of underlying danger, Medicare fraud, waste, and abuse can be easily avoided as well as prevented. If the measures for safety are taken, then it may be brought to a complete and utter stop. All of the information presented here can be found in a more in-depth toolkit presented by Centers for medicare and medicaid services otherwise known as CMS. MedTrainer offers extensive and captivating courses on the precautionary steps to take as to how to stop Medicare, Fraud, Waste, and Abuse. Join us today in creating a more beneficial and productive medical field, free of theft and fraud. Visit http://medtrainer.com/demo/ to learn more, as well as schedule your free demo.