1. Ann Williams Investigator Eastern District of Texas

2.  What we do  What is the False Claims Act?  What is Medical Billing Fraud?  Misconceptions  Effects  Prevention/Solution  Why should you care?  Examples of Cases  Q&A

3.  Recover taxpayer funds lost by fraud  Impose penalties against offenders  Protect program integrity  Serve as strong deterrent against fraud

4. CriminalCivil Specific Intent to DefraudNo Specific Intent Needed Proof Beyond a Reasonable Doubt Preponderance of the evidence

5.  31 U.S.C. 3729 – 3733  “Lincoln Law”  Qui Tam provision

6. Actual Damages x 3 PLUS $5,500 - $11,000 PER CLAIM PLUS Agency Debarment / Exclusion

7.  Seven prohibited acts  31 USC 3729(a)(1)(A) through (G)  Whoever knowingly presents, makes or causes to be presented a false or fraudulent claim  To receive money from the US  To avoid paying money to the US (reverse false claim)

8.  Was the Claim “knowingly” submitted?  Actual knowledge the information is false  Deliberate ignorance of the truth or falsity  Reckless disregard of the truth or falsity  No specific intent required

9.  “We didn’t directly submit the claim.”  “The claim was caused by a rogue employee.”  “The false claim was denied / not paid.”  “I paid it back.”  “I was acquitted in the criminal case.”  “I was convicted in the criminal case and double jeopardy applies.”

10.  Simply put, it is billing for an item or service that wasn’t provided in the manner in which it was claimed.  99211 vs. 99214  Custom vs. off-the-shelf items  K0011 vs. K0001 vs. K0800

11.  Fraud vs. abuse  Health care fraud is a victimless crime

12.  Costs the taxpayers billions of dollars in worthless or not provided goods and services  May support organized crime  May cause patients denial in claims later in life  Creates a dependency that didn’t exist before

13.  You may be an accessory to a crime  You may be excluded from all programs

14.  Billing for services not rendered  Upcoding  Downcoding  Double billing  Providing medically unnecessary services  Kickbacks  Alteration of documents  Forgiving the co-pay routinely

15.  What you should look for:  Claims that are abnormally skewed  Claims in which every patient receives that same treatment  Claims for patients in different locations from the provider  Provider telling you to unbundle claims  Multiple providers in a group billing for the same patients  Sharp spikes in certain codes  Time-based codes that exceed 24 hours in any given day

16.  In your own practice  Screen all potential new hires for exclusion status  Stay current with new codes and interpretations  Attend regular training  Document instances that you believe are not correct  Make sure your contracts with providers cannot be considered kickbacks  Don’t accept or offer kickbacks in any form  Safeguard PII with secure systems and document destruction

17.  Maximizing the billings  Aberrations that can be explained  Specialists may have skewed claims

18.  Call the OIG Hotline:  1-800-477-8477  Call the payor’s hotline  Medicaid, Blue Cross, etc.