EXECUTIVE SUMMARY

Frequent and thorough compliance training is necessary for hospital case managers, as well as other healthcare professionals and staff. The goal is to prevent healthcare fraud, waste, and abuse.

  • The U.S. Health Care Fraud and Abuse Control Program investigates allegations of abuse and often reaches costly settlements with healthcare organizations.
  • The government’s return on investment for fraud and abuse investigations is from four to six times the money spent on the investigations.
  • Overbilling, overlapping services, padded billing, and documentation that does not meet the funder’s payment standards are some of the red flags of fraud, waste, and abuse.

All hospital employees, including case managers, should receive frequent compliance training that includes information about how to prevent problems with fraud, waste, and abuse.

“Receiving training is one of the most effective ways to prevent fraud, waste, or abuse issues,” says Chris Ambrose, MBA, CHC, CHPC, healthcare compliance officer at Service Access and Management Inc. of Reading, PA.

“Without effective training, case managers are put in a position to break policies, rules, or laws they don’t even know about,” Ambrose says.

The government recoups about $4-$6 for every $1 spent on preventing and detecting issues related to compliance, according to the Office of Inspector General (OIG).

According to the 2018 report, the Health Care Fraud and Abuse Control (HCFAC) Program’s investigations recovered four times the amount spent. (The report is available at: http://bit.ly/2UOnDxb.)

Earlier OIG reports showed an even bigger return on investment, with a five-to-one return on fraud and abuse investigations investment in the 2017 report, and $6.10 collected for every $1 invested, according to data from Fiscal Year 2015. (The reports can be viewed, respectively, at: http://bit.ly/2LkCdIj and http://bit.ly/2QX4JFc.)

This shows how government healthcare funders scrutinize case management and the healthcare industry as a whole, Ambrose says.

“It, therefore, is imperative — through effective training — that case managers have an absolute understanding of their respective program’s payment standards,” he says.

The federal government incentivizes anyone who is concerned with potential violations of fraud, waste, and abuse laws by awarding whistleblowers who report suspected false claims information with up to 30% of what is recouped in a substantiated allegation. (More information can be found at: http://bit.ly/2GmZ1bP.)

In the fee-for-service reimbursement environment of case management, the government and funding organizations rigorously monitor and pursue cases of billing for services that are inconsistent with program requirements.

Overbilling, overlapping services, padded billing, and documentation that does not meet the funder’s payment standards are just a few of what case management funders in the fee-for-service environment consider red flags of noncompliance, Ambrose says.

For example, there are several recent cases that illustrate how costly false claims can be — even if the problem was a documentation or other mistake that was later reported by the clinician to the government:

• December 2018: A hospice care provider agreed to pay $5.86 million to the federal government to settle False Claims Act allegations. The provider submitted Medicare claims for hospice care that was medically unnecessary or lacked documentation. (https://bit.ly/2R0OtTJ)

• May 2018: A hospital in Coudersport, PA, paid the United States $373,547.54 to settle allegations from two self-disclosures to OIG. The hospital billed incorrectly for services and failed to see some Medicare hospice patients in person, although they were billed for this service.

According to OIG, the hospital took corrective action and voluntarily disclosed the problem, so it was settled without litigation. (http://bit.ly/2EnLJt0)

• April 2018: A physician and owner of a pain clinic in Scranton, PA, had submitted numerous improper claims for payment by upcoding care to receive a higher reimbursement amount, between 2003 and 2014, which is when the physician died. The settlement resulted in the physician’s estate agreeing to pay the United States $625,000 to settle the False Claims Act allegations. (http://bit.ly/2EnLJt0)

• November 2014: HHS investigated a healthcare fraud case involving a psychiatrist in Mt. Carmel, PA. The psychiatrist was charged with false billings for psychotherapy services, including for face-to-face therapy sessions when he actually was out of the country. The total amount of his fraudulent billing was $322.75.

In a plea agreement, the psychiatrist acknowledged guilt to six misdemeanor charges and agreed to pay a total of $95,000 to the government. (http://bit.ly/2QVjCb0)

“This underscores the importance of having an effective compliance program — inclusive of effective training, which encourages staff to come forward, internally, if they suspect problems,” Ambrose says. “Organizations should have a non-retaliation policy that ensures staff will not be disciplined for reporting.”

Health systems and other healthcare organizations operate multiple types of case management programs, and these often feature their own unique funding standards.

This is why it’s crucial that case management directors and supervisors, who have direct responsibility for the case management program, remain on the front lines to ensure adequate training, Ambrose says.

Training should address the distinct payment standards for each program, he explains.

“Inadequate training often is the catalyst for case managers to cause unnecessary costs to funders, which leads to fraud, waste, or abuse issues,” Ambrose says.

In addition to compliance training, effective compliance programs require a robust monitoring and auditing effort.

“An effective compliance program is one that will enable all staff to become the eyes and ears of the company,” Ambrose says.

“Ideally, monitoring and auditing efforts will take place prior to claims reaching the funder,” he adds.

Proactive measures, like monitoring/auditing, enable the case management organization to resolve issues before claims are submitted.

“In my experience, fraud, waste, and abuse training that simplifies the legalese for staff is engaging,” Ambrose says.

Training can be provided in a way that is exactly relevant to how an organization does business, he says.

Fee-for-service payment case management programs typically are more vulnerable to compliance concerns than other payment models, such as grants, capitated care, population health, and bundled payments.

These other funding models generally involve a set payment that covers all the work they do in caring for patients versus the fee-for-service model, which results in multiple claims per day, per case manager.

While accurate billing is vital, accurate documentation is equally important to prevent False Claims violations, Ambrose says.

Documentation of case management services must demonstrate that the claims meet the funder’s payment standards. If they don’t, they can lead to an overpayment and cause a fraud, waste, or abuse concern.