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Healthcare Fraud


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Health Care Billing and Fraud Prevention Tips

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Healthcare Fraud

  1. 1. Hospital Billing and Fraud Michael Argust Healthcare Consultant Argust Consulting, LLC Twitter: Consultweet Facebook Fan Page
  2. 2. <ul><li>01/18/2010 </li></ul><ul><li>Medicare fraud suspect arrested in Cancun </li></ul><ul><li>Federal agents caught up with suspected Medicare scammer Jose Luis Perez in the resort town of Cancun and flew him back to Miami over the weekend to face a $179 million health-care fraud indictment. </li></ul><ul><li>See Article </li></ul>Miami Fraud of $179 million Billing for Services Never Rendered
  3. 3. Billing Fraud Is Prevalent <ul><li>Prevent Billing Fraud </li></ul><ul><ul><li>Set the Tone: Zero Tolerance! </li></ul></ul><ul><ul><li>Have regular board audits: Review duties and powers </li></ul></ul><ul><ul><li>Discourage Errors: Publish fraud captures and penalties </li></ul></ul><ul><ul><li>Formalize Policies and Procedures: Monitor quality </li></ul></ul><ul><ul><li>Establish Compliance Program: Mitigate errors </li></ul></ul><ul><ul><li>Train Hospital Staff Latest Regulations: Identify issues </li></ul></ul><ul><ul><li>Update Charge Master: Remove discontinued items </li></ul></ul><ul><ul><li>Supervise inexperienced staff: Billers, Coders </li></ul></ul>
  4. 4. <ul><li>12/15/2009 </li></ul><ul><li>Feds arrest 26 in $61 million Medicare fraud </li></ul><ul><li>FORT LAUDERDALE, Fla. - Federal agents arrested 26 suspects in three states Tuesday, including a doctor and nurses, in a major crackdown on Medicare fraud totaling $61 million in separate scams. </li></ul><ul><li>See Article </li></ul>Fort Lauderdale Fraud of $61 million Billing for Services Never Rendered
  5. 5. Common Hospital Billing Errors <ul><li>Duplicate Billing </li></ul><ul><li>Inaccurate Dates of Service Billed </li></ul><ul><li>Incorrect Room Charges </li></ul><ul><li>Up-Coding or Unbundling Charges </li></ul><ul><li>Keystroke Errors </li></ul><ul><li>Billing for Canceled Work or Tests </li></ul><ul><li>Billing for Services Never Rendered </li></ul>
  6. 6. <ul><li>01/14/2010 </li></ul><ul><li>Agents arrest 13 Detroit residents in alleged Medicare fraud plot </li></ul><ul><li>Thirteen metro Detroit residents were arrested today by federal agents in connection with an alleged home health care plot to defraud Medicare of more than $14.5 million between August 2007 and September 2009, according to a statement by the U.S. Department of Justice. </li></ul><ul><li>See Article </li></ul>Detroit and Southeast Michigan's premier local business news and information Web site Detroit Fraud of $14.5 million Billing for Services Never Rendered
  7. 7. Duplicate Billing <ul><li>Ensure the records are accurate </li></ul><ul><li>Ensure proper authorization </li></ul><ul><li>Query the data for duplicates, check for same services, same date, same time, same patient being billed </li></ul><ul><li>Perform regular billing audits </li></ul>
  8. 8. <ul><li>06/24/2009 </li></ul><ul><li>Couple charged with health-care fraud </li></ul><ul><li>A Houston area doctor and his wife, also a physician, were charged Wednesday in federal court, accused of illegally prescribing more than 600,000 pain pills and billing the government more than $8 million for medical care that was never performed. </li></ul><ul><li>See Article </li></ul>Houston & Texas News Houston Fraud of $8 million Billing for Services Never Rendered
  9. 9. Inaccurate Dates of Service <ul><li>Check Admission and Discharge dates accuracy </li></ul><ul><li>Reconcile times and dates for Emergency Room </li></ul><ul><li>Run reports that check against operating room logs, anesthesiology time and time of discharge </li></ul><ul><li>Prevent irregularities with variance analyses </li></ul>
  10. 10. <ul><li>01/22/2010 </li></ul><ul><li>New Orleans 77 Year old doctor indicted for healthcare fraud </li></ul><ul><li>U.S. Attorney Jim Letten says Dennis allegedly submitted claims in the amount of $102,053 to the U.S. Department of Labor's office of worker's compensation programs for services provided after Hurricane Katrina but did not render. </li></ul><ul><li>See Article </li></ul>New Orleans Fraud by Dr. 77 yrs. old Billing for Services Never Rendered
  11. 11. Incorrect Room Charges <ul><li>Set formal Policies and Procedures for charging </li></ul><ul><li>Accurately document private room requests and needs </li></ul><ul><li>Check for unnecessary un-requested private room charges </li></ul><ul><li>Establish and monitor variances to standards </li></ul>
  12. 12. <ul><li>01/16/2010 </li></ul><ul><li>Doctor accused of healthcare fraud </li></ul><ul><li>A Massachusetts-based doctor, Dr Scott Reuben was accused of one count of healthcare fraud. According to the U. S. Department of Justice on Thursday the doctor was charged with fraud in federal court in Boston. He faked medical research studies, some of these studies were even published in medical journals. </li></ul><ul><li>See Article </li></ul>Massachusetts Faked Medical Research Studies
  13. 13. Keystroke Errors, Cancelled Work <ul><li>Discourage Errors </li></ul><ul><li>Communicate cancelled work to other departments </li></ul><ul><li>Ensure proper authorization has been given </li></ul><ul><li>Provide proper documentation </li></ul>
  14. 14. <ul><li>29 Jan 2010 </li></ul><ul><li>COSHOCTON -- Documents hidden in their Forest Hill Drive home led to the arrest of a Coshocton couple. </li></ul><ul><li>Barbara Elise Miller, 55, of Coshocton, and her husband, Dana Campbell, 50, were arrested Thursday morning and indicted on federal charges, according to the Ohio Attorney General's Office . </li></ul><ul><li>See Article </li></ul>Fraud in Ohio Billing for Services Never Rendered
  15. 15. Up Coding <ul><li>The computer did it! </li></ul><ul><li>Over $900,000 error </li></ul><ul><li>Consultants save over $3,000,000 in six months </li></ul><ul><li>Consultants showed them where their reimbursement was and where their cost was. </li></ul><ul><li>Doctors are taken aback with data on costs </li></ul>Medical Bill Error of $962,120 See Article
  16. 16. Hospital Billing and Fraud Michael Argust Healthcare Consultant Argust Consulting, LLC Thank You