Quick, define fraud and abuse

Congratulations, you haven’t been watching MTV

Fraud and Abuse. The words are as familiar to home care providers as Bevis and Butthead are to the MTV Generation. However, where MTV’s bad boys will only insult your intelligence, Fraud and Abuse will land you in jail.

Everyone from the President, the Department of Health and Human Services, the Office of Inspector General, the Health Care Financing Administration, the FBI, and the IRS to Oprah have talked about it publicly.

But do you as a director of a hospital-affiliated home care agency fully understand where you stand on the issue with the government?

Fraud and abuse have been around in one form or another for generations, but Medicare fraud drew much attention with the passage of the Fraud and Abuse Provisions of the Health Insurance Portability and Accountability Act of 1996, a.k.a., Kassebaum/Kennedy Act. It’s now a cause clelebreamong our nation’s bureaucrats.

But it also catches much of the attention of fiscal intermediaries such as Palmetto Government Benefits Administrators in Camden, SC, which devoted an entire issue of its provider newsletter, MEDICARE Advisory to the subject.

To help providers better understand what the government means, Palmetto provides the following definitions:

Fraud:An intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and commits, knowing that the deception could result in some authorized benefit to himself or herself or some other person. The most frequent kind of fraud arises from a false statement made, or caused to be made, that is material to entitlement to the Medicare program. The violator may be a participating provider, a beneficiary, or some other person or business entity.

Abuse: included incidents or practices of providers, physicians, or suppliers of services who are inconsistent with accepted sound medical practices, directly or indirectly resulting in unnecessary costs to the program, improper payment or program payment for services that fail to meet professionally recognized standards of care or are medically unnecessary.

Palmetto also cautions providers about kickback provisions of the Social Security Act. { Federal law Section 1128B of the Social Security Act [42 USC 1320a-7b(b)].} The law says the following activities are illegal:

1. To knowingly and willfully solicit or receive any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or kind:

A) in return for referral in individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program or,

B) in return for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing or ordering any good, facility, service, or item for which payment may be made in while or in part under a Federal health care program, shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five years, or both.

. Whoever knowingly or willfully offers or pays any remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such a person:

A) to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or

B) to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in while or in part under a Federal health care program, shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five years, or both.

Palmetto notes that "the anti-kickback provisions are very broad. The remuneration referred to above does not have to be money. It can be anything of value transferred in any way whatsoever. This would include discounts, incentives, gifts, and providing free services, as well as direct payments. The penalties do not just apply to the person or entity that offers the payment. They also apply to the person who accepts or requests the payment. If the incentive, payment, or offer is designed to result in service for which the Medicare program will pay, it may violate these provisions."

Some examples of potential violations are:

• discharge planners and/or nurses being installed in hospitals, physician offices, skilled nursing facilities, retirement homes, or assisted living facilities (ALFs) by a home health agency free of charge;

• physicians, discharge planners, or social workers who receive compensation from a home health agency for patient referrals;

• payment of a fee to a physician for each plan of care certified by the physician on behalf of the home health agency;

• offering free services to beneficiaries, including transportation and meals, if they agree to switch home health providers.

(See story, p. 26, for examples of Safe Harbors, which are exceptions to these laws.)

[Editor’s note: For more information on home
care fraud and abuse, contact Jennifer Lombardo, Home Health and Hospice, Palmetto Government Benefits Administrators, South Carolina Part A Intermediary, 2300 Springdale Drive, P.O. Box 7004, Camden, SC 290020-7004. Telephone: (803) 799-0222, Ext. 38181.] n