Essay on Healthcare

This essay has a total of 1466 words and 11 pages.


Unrestricted National Medicare Fraud Alert (UMFA 9802, issued June 9, 1998) REVISED
October 6, 1998(Revisions are Shown in Italics): Billing for Services Not Rendered or Not
Medically Necessary; Upcoding (Billing for Powered Wheelchairs and Delivering Power
Operated Vehicles (POVs)); and Exchanging Power Wheelchairs for POVs After the Wheelchairs
Were Paid.

DME companies are utilizing three mechanisms to obtain inappropriate reimbursement for
power vehicles, primarily for beneficiaries in Florida. The three mechanisms are:

1. They (the DME companies) bill for services not rendered or not medically necessary; or
2. They deliver a POV (scooter) and bill for a power wheelchair; or
3. They deliver and bill for a power wheelchair, and after receiving payment go back to
the beneficiary and exchange it for a POV.

The primary AK@ codes appearing were - K0011, K0021, K0031, K0034, K0067, K0073, K0081,
and K0086. All these codes appeared in the beneficiaries= EOMBs. Codes E0192, E1399, and
L0700 were billed in different combinations with the above AK@ cod


These companies were submitting a large number of claims for CPT Code 93268 -
transtelephonic arrhythmia monitoring test and for the following range of codes from 93270
- 93272, 93012-93014 and codes G0004-G0016.

When 93268 is billed, 93270, 93271 and/or 93272 should not be billed.
These companies were also under investigation for submitting fraudulent claims for
surgical dressings and incontinence supplies.

Contractors should look for the following:
Claims for numerous beneficiaries residing at the same address.
"Impossible date of service scenarios" such as a provider rendering volumes of services
which seem potentially impossible.

Doctors who work for the suppliers and beneficiaries that reside outside of the carrier jurisdiction.
Doctors who make no other appearance in the beneficiaries histories other than being the
ordering physicians on the IPL's claims.

Multiple carriers paying for the same beneficiaries.

Listing of Medicare Fraud Alerts
The Health Care Financing Administration (HCFA) issues a fraud alert when it has
identified an apparent Medicare scam or fraudulent scheme, which is operating in multiple
States. Alerts are appropriate if the scheme represents a potentially significant loss in
dollars to Medicare or poses a threat to patient health or safety. HCFA issues alerts to
all Medicare fraud units, federal and selected State law enforcement agencies, and as
appropriate, provider and beneficiary groups. The purpose of the alerts is to enable
Medicare, its providers, and its program beneficiaries to protect themselves from
fraudulent schemes.

There are two classifications for fraud alerts, Unrestricted and Restricted. The
unrestricted alerts furnish detailed information on the scheme but they do not identify
specific providers thought to be involved in the operation of the scheme. Restricted
alerts describe the scheme and specify suspected providers and entities. Because the names
of providers under investigation are not disclosable, we delete all provider-identifying
information from the text of the alert.


Health Care Financing Administration
National Fraud, Waste and Abuse Conference
March 17, 1998
Summary of Major Themes*
Disclaimer: The statements included in the following conference proceedings are from a
variety of sources and are not necessarily endorsed by the Health Care Financing
Administration. Futhermore, the transcript portion of the proceedings has not been edited.

Best Practices

Improve provider enrollment processes:
o use site visits to verify provider addresses
o in person application process
o provider application forms should be consistent across the country, and should be
developed in consultation with U.S. Attorney=s office to insure that false statements on
application forms can be prosecuted

o require providers to periodically report on employees and financial backers
o utilize credentialing as a gatekeeper to the program
o follow new providers for a certain period of time--watch their billing patterns

Promote education:
o beneficiaries need to be educated about program and fraud issues; find best vehicles in
each community (for example, area units on aging, advocacy groups, clergy, etc.)

o target particularly vulnerable beneficiary populations, such as immigrant groups
o Explanation of Medicare Benefits (EOMBs) need to be sent out in a more timely fashion
o all Medicaid beneficiaries should receive EOMB type statements and be encouraged to
review for inconsistencies with care provision

o more provider education, including better communication of policies
o help beneficiaries understand that addressing fraud should not reduce access to legitimate medical services

Encourage and support development of corporate compliance programs:
o more consistent guidance and interpretation from HCFA and oversight groups about proper
practices (for example, documentation)

Promote administrative simplification:
o make Medicare and Medicaid rules easier for beneficiaries and providers to understand
o make it easier for beneficiaries to asked questions, report fraud

Zero tolerance policy for fraud:
o a zero tolerance message needs to be enforced and emphasized throughout the provider community as well as government.
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