Here is the information based on the provided content: "Understanding Health Care Fraud, Waste, and Abuse in SIU
Gain insights into the costly impact of health care fraud, the definitions of fraud, waste, and abuse, the responsibilities of Special Investigations Units (SIU), and the critical role of SIU in compliance programs within health plans.
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Select Health Special Investigations Unit
The Cost of Health Care Fraud As a nation, we spent $4.3 trillion on health care goods and services in 2021. Conservatively, at least three percent, or $129 billion, is what the National Health Care Anti-Fraud Association estimates will be lost to fraud. Other estimates by government and law enforcement agencies place the fraud at ten percent or $430 billion
What is Health Care Fraud? Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representation, or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program.
What is Waste? Careless expenditure, mismanagement, or abuse of resources. Also includes unnecessary costs resulting in inefficient or ineffective systems or controls.
What is Abuse? Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to get paid. Abuse cannot be differentiated categorically from fraud because the distinction between fraud and abuse depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.
SIU Responsibilities Detection, prevention, investigation, and reporting of fraud, waste and abuse Partner with local and federal law enforcement agencies, regulatory agencies and other SIU s in the region Partner with internal departments Claims, Payment Integrity, Provider Contracting, Compliance Provide training for employees
SIU and Compliance The SIU is a critical part of any Health Plan compliance program An SIU/Anti-Fraud program is required by CMS and most states to conduct business Federal statutes that apply to government lines of business- False Claims Act Anti-Kickback Statute Stark Law
SIU Toolbox SQL data querying Medical records review Court records Public websites OSINT framework State business license search DOPL County Assessors searches Social Media Fraud detection software - AI Specialized certifications and training AHFI, CFE, CPC Information sharing HFPP, NHCAA(SIRIS), ACFE
SIU Process Intake/Case triage Hotline anonymous tip Customer Service, Claims, Provider Reps RFI Law Enforcement Info Share Meetings Proactive review Investigation Data Analysis/Financial Exposure Records Review Social Media Research Licensure Validation Interviews On-site Audit
SIU Process Referral or administrative action State and federal law enforcement agencies State regulatory agencies Internal administrative action contract termination or policy recission Pre-Payment review Financial recoveries Hard/Soft $$ Overpayment recoveries Claims offset New policies or edits Change in behavior
Types of Healthcare Fraud Provider Fraud Member Fraud Application Fraud Broker Fraud
Provider Fraud Performing Medically Unnecessary Procedures Billing for services never rendered Misrepresenting non-covered treatments as medically necessary treatment to obtain payment Up-coding Accepting kickbacks for patient referrals Unbundling
Member Fraud Schemes ID Theft Receipt Forgery Prescription Drug Abuse Dr. and ER Shopping Prescription Forgery
Doctor & ER Shopping Doctor Shopping Practice of visiting multiple physicians to obtain multiple RX s or the medical opinion that one wants to hear. Emergency Room Shopping Seeking injectable drugs Seeking attention, comfort, love and care Common diagnoses: back/neck pain, kidney stones, tooth ache, migraines, abdominal pain
Application Fraud Obtaining a policy of insurance, or a specific coverage, by use of false, incomplete, or misleading information when the policy would not otherwise be issued, and the coverage would not otherwise be approved.
DME Issues Falsifying doctor s orders to qualify member for power wheelchair when a standard wheelchair was prescribed.
Misrepresenting Items $225 Allowed
Randy Maurer Investigator Special Investigations Unit SelectHealth 801-442-9048 Randy.Maurer@selecthealth.org
