Be vigilant when it comes to fraud/abuse compliance
Be vigilant when it comes to fraud/abuse compliance
CMs may be responsible if they fail to report
With the Office of the Inspector General (OIG) announcing its intention to cut down on Medicaid and Medicare fraud, it is more important than ever for case managers to make sure that they report any fraudulent conduct and carefully document it to avoid being held responsible, Elizabeth Hogue, Esq., suggests.
Government enforcers must prove intent in the case of fraud, but they often cast a wide net that can include case managers in the mix, adds Hogue, a Burtonsville, MD, attorney in private practice, specializing in health care. "If a case manager knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that they had intent, and the courts have backed them up," she says.
When a case manager shows reckless disregard for a pattern of fraudulent conduct, regulators have the necessary information to prove fraud, the courts have ruled. "Fraud is more than just submitting claims for care that the patient didn't receive. Case managers must become vigilant to prevent patterns of fraud and abuse," Hogue says.
Don't be tempted to think that fraud and abuse compliance is the responsibility of hospital management or the compliance officer, she warns.
Under the Medicare/Medicaid Fraud and Abuse Compliance program, every health care practitioner, regardless of his or her position is responsible, Hogue adds.
The OIG has ruled that every health care practitioner has personal and individual responsibility for fraud and abuse compliance, whether they were directly responsible.
"The OIG has taken this position because the OIG realizes that the problem of fraud and abuse will never be resolved until every practitioner takes individual responsibility for it," Hogue adds.
If you notice a pattern of fraud and abuse, report it to your hospital's compliance officer and go up the chain of command to the chief executive office until you get an appropriate response, Hogue advises. Document what you observed and the steps you took in reporting it, she adds.
One of the most frequent examples of fraud and abuse that a case manager might see is a violation of a patient's right to freedom of choice for post-discharge care, Hogue says.
"The OIG has indicated that it is a violation of the Medicare conditions of participation when a hospital discharge planner doesn't give the patient a choice but assumes that the patient would be happy with one agency or another," she says.
Case managers have been held responsible for violation of patients' rights to freedom of choice.
"I've had clients who made reports to a hospital about violations, based on signed statements from patients. The discharge staff were held responsible because they weren't abiding by the Medicare Conditions of Participation," Hogue says.
In the case of post-discharge services, having the patient sign something is not required, but it's a good idea to come up with a consistent way of documenting that the patient is given a choice, she says. "The underlying principle here is that the OIG is always concerned when providers refer patients to the entities in which they have a financial interest. That is at the heart of a lot of the fraud and abuse investigations, especially when patients are 'steered' to entities owned by hospitals without being given an opportunity to choose providers."
A case manager might become aware of services that another practitioner documents that were never rendered to put in a claim for reimbursement. For instance, if a physician claims to have visited the patient in the hospital a certain number of times, the case manager might know better. A case manager might be in the position to observe money or expensive gifts change hands from post-acute providers who want referrals or might be offered gifts themselves.
Case managers can safely accept nonmonetary items of nominal value, Hogue says. "Unfortunately, there is no guidance that is more specific. Case managers should be very careful if they are offered money or gifts. Small gifts, nonmonetary gifts, excluding gift cards and gift certificates, are OK because they are unlikely to produce a referral."
The OIG enforcers are alerted to incidents of potential fraud and abuse in a number of ways, including reports by employees, patient complaints, and routine audits.
Patients are getting more knowledgeable about their right to choose and may indicate that they want a home health agency they have used in the past. "Often, patients have a relative or a friends who works for a home health agency or serve on the board. They alert the patients that they have a choice," Hogue says.
For more information, contact: Elizabeth E. Hogue, Esq., at (301) 421-0143, or [email protected].
With the Office of the Inspector General (OIG) announcing its intention to cut down on Medicaid and Medicare fraud, it is more important than ever for case managers to make sure that they report any fraudulent conduct and carefully document it to avoid being held responsible, Elizabeth Hogue, Esq., suggests.Subscribe Now for Access
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