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Every year, millions of dollars are improperly spent because of fraud, waste, and abuse. This can be halted and prevented if the process of detecting, correcting, and controlling, is followed by fraud, waste, and abuse training.  

This process is required by The Social Security Act, as well as CMS regulations. It is stated that those who supply Medicare and Medicaid services are required to have an effective compliance program that includes measures to prevent, detect, and correct acts of Medicare and Medicaid non-compliance.

Fraud Prevention Initiatives for the Healthcare Industry

There must also be implemented measures to prevent, detect, and correct fraud, waste, and abuse. These steps and efforts must be provided via effective training for employees, managers, directors, and 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 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 by fraud waste and abuse awareness training. Being the most crucial step in halting fraud is to go to the most vulnerable portion of information and ensure its safety. The most common types of fraud and abuse in the Medicaid program include medical identity and theft, unnecessary billing, upcoding, unbundling, and beneficiary fraud.

Types of Medicare and Medicaid Fraud

Medical identity theft, the most common form of fraud, involves the misuse of a healthcare professional’s 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 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, state medical license number, and Medicare number. Physician medical identifiers are used for such things as identifying the physician of record on Medicare 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.

Medical Identity Theft

An excellent example of medical identity misuse 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, they used the pads to forge more than 250 prescriptions for painkillers. By using stolen Medicaid cards, they were able to bill the prescriptions to the Medicaid program for a total of more than $200,000. The perpetrators 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 secure location.

Improper Medical Billing to Medicare and Medicaid

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 services or items vary from state to state. Only medical equipment 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, and it will stop you and your organization from the 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 patients’ medical condition did not qualify for that level of transportation.

MedTrainer®: Helping Healthcare Organizations Tackle Fraud, Waste, and Abuse

Although it may sound like a complex network of underlying danger, Medicare fraud, waste, and abuse can be easily avoided as well as prevented by awareness training. If the measures for safety are taken, then instances of fraud, waste, and abuse can be significantly curtailed or stopped altogether.

All of the information presented here can be found in a more in-depth toolkit presented by the Centers for Medicare and Medicaid services, otherwise known as CMS. An analysis of summary notices, abuse identifiers, and tools to report fraud can be found there as well.

As part of satisfying the fraud, waste, and abuse compliance training requirements established, 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.

Learn more and schedule your free demo with MedTrainer® today!