The Medicare Fraud Strike Force has charged more than 3,700 people for $14 billion in false billings in the Medicare program since 2007, and the current administration is aggressively targeting billing schemes that rob Medicare, Medicaid, and other insurance programs. (

Recent settlements between healthcare providers and the United States include a $5.86 million False Claims Act resolution with a hospice care provider that allegedly submitted claims to Medicare that either were for medically unnecessary treatment or lacked documentation. In another case, a healthcare organization paid $12.5 million to resolve False Claims Act liability for fraudulent billing. (

Case management departments can prevent False Claims Act violations by training case managers to follow the rules set by their program funders and payers, including the Centers for Medicare & Medicaid Services (CMS).

“Case management programs reimbursed on a fee-for-service process are the most vulnerable to fraud, waste, and abuse issues,” says Chris Ambrose, MBA, CHC, CHPC, healthcare compliance officer at Service Access & Management in Reading, PA.

The fee-for-service model sets definitive billing and reimbursement requirements, and case managers should know precisely what these are. (See list of noncompliance red flags in this issue.)

For example, some payers do not allow case managers to bill for the time it takes them to travel between visits with patients. Early intervention case management in Pennsylvania has an exception to this rule, and case managers can bill for travel between their appointments with very young patients, Ambrose says.

“This varies between states and programs,” he adds. “The point is that case managers and case management directors need to have an absolute understanding of what their funders’ service and reimbursement requirements are.”

Without that understanding, they could inadvertently run afoul of fraud and abuse laws.

Ambrose offers these suggestions for how case management programs can prevent compliance problems:

• Train on service delivery requirements. “Training is the most effective way to prevent fraud, waste, and abuse issues,” Ambrose says.

Case management directors should word explanations of fraud and abuse laws in clear, simple language, avoiding legalese, he suggests.

“I provide simplified versions of legal definitions and scenarios that are related to their work,” Ambrose says.

For example, Ambrose might explain a billing scenario in which a case manager was providing services to the mother of a client. The service notes did not indicate that any service was provided to the client.

“As a case manager, often times you do need to help family members of clients, and our funders understand that,” he explains. “But the note has to reflect that the service goes back to the client and the client is the one who benefits from the service.”

If documentation does not show that the patient benefited from the service, the funder will not pay for that service.

Or, in a worst-case scenario, the funder might have paid the bill but later audited it and discovered that the documentation did not justify payment — a potential compliance issue.

“We provide six different types of programs funded on a fee-for-service basis, and each of those six programs has a different service delivery requirement,” Ambrose says.

Case management departments should provide definitive and detailed training about each service delivery requirement, he adds.

• Provide hands-on training. Compliance training might start in the classroom, but it also should include having staff follow a supervisor to learn how to bill appropriately, Ambrose suggests.

“Classroom training is good, but it’s not enough,” he says. “It’s equally important to be in the field with the case manager.”

New staff might need a week or longer of shadowing the supervisor and experienced case managers. “They need to see what it looks like to be an effective case manager who knows how to provide case management per the funders’ requirements and when billing on fee for service,” Ambrose says.

• Reinforce the importance of preventing fraud, waste, and abuse. Every unit of service that case managers bill has the potential to be billed incorrectly.

Case managers need tools to help them track their 15-minute units of service effectively.

“There are apps I’ve seen case managers use that will track their travel time, so they know not to bill during those times,” Ambrose says. “They need to enter the exact start and end times in their Outlook calendar or an activity log or notebook.”

Some type of log ensures accuracy. When it’s time to write a case note about the service delivered, the case manager who uses a log will have an accurate record of when service started and ended, he explains.

“They’re not putting themselves into a position to rely on their memory of what time the service ended,” he adds.

• Document accurately, without fail. Many of the federal government’s fraud cases include allegations of poor or missing documentation. For instance, if a case manager provides a billable service for a patient but fails to document it accurately, it could result in an allegation of fraud.

“Documentation has to reflect the exact requirements that a particular funder expects,” Ambrose says. “For example, with the case management programs we provide, there has to be a purpose of case management involvement that is well documented.”

It’s not enough to write a service note. The documentation must reflect the client’s service plan, goals, and how the case management visit fit into that plan, he says.

• Use audits to learn and correct. “Our programs are audited throughout the year by our funders, so we have an idea from those audit results where the funders are focused,” he says. “We pass this information on to our staff during training.”

For example, Ambrose has found that funders currently are focused on documentation that does not substantiate billed time. So if a case manager billed for eight units, which is two hours of service, the documentation must show a service that would take two hours to complete. This particular service must be in the client’s service plan.

“If they chat with patients about what they had for dinner last week, then that likely will not relate to the patient’s goal of obtaining employment, for example,” he explains.