This text-based course is a transcript of the live seminar, “Fraud, Abuse, Audits & Appeals: What Therapists Need to Know,” presented by Mary R. Daulong, PT, CHC, CHP.
>> Mary Daulong: Before we begin, I would like to ask a few questions. How many of you are physical therapists? How many of you are business office managers or staff? I wanted to get a feel for the audience to see if we have a vantage point one way or another.
Today’s presentation will not be the answer-all for everything, but I will give resources for you to refer back to as needed.
Why the Focus on Fraud and Abuse?
Why are we interested in fraud and abuse? Why is the government in almost every single newspaper on a daily basis talking about fraud and abuse, especially as it relates to the federal programs? We are looking at 1 trillion dollars of government spending on Medicare and Medicaid programs. They are estimating 3% to 10%, with the extreme side being 100 billion dollars, of fraud. Obviously, this is very important to focus on. They have created a number of programs to combat fraud which are administered by the attorney general’s office and the secretary of health and human services. They are working at a federal level as well as a state level to combat the fraud and abuse that exists throughout the nation. Prior to 1986, we did not hear much about fraud and abuse. Since they have put the numbers together, it has been a significantly important focal point for them.
Fraud and Abuse Control Programs
The first program is the Medicare Integrity Program. It does have a number of functions. They do a lot of data mining. They are looking at detecting aberrant billing and coding behavior by the providers. They do auditing with utilization reviews and requesting of charts. Education is the proactive function that they do provide, and your MACs (Medicare Administrative Contractors) are responsible for providing education to the providers of the federal program services and beneficiaries as well. You are seeing more and more information on how to do things correctly. Primarily in the past, the MACs, who were called carriers and fiscal intermediaries, were responsible for education. It varied quite a bit as far as what that function was because it is not something that is compensated to those particular contractors. Now CMS is providing more and more resources to the MACs, so education has certainly improved.
We also have the Beneficiary Incentive Program for people who may have seen a Medicare Beneficiary summary. It talks about what they can do to submit a suspected or known fraud, and also tells them of the financial benefit that it would be to them should there be some recovery. This is the Qui Tam provision which is the whistleblower provision. For example, many of our seniors with very limited finances would have a higher incentive to watch things very carefully. We are hearing a lot more questions from our patients about their bills. “You did this on one day and this on another day, but the bill was the same/different than I think were provided.” You will probably continue to see that escalate.
As mentioned, there is the notice to the beneficiaries, but there is also another important aspect called the Senior Medicare Patrol. These are people who are being trained and educated on how to look at different aspects of provider services including the billing. With those programs and forces together, we have quite a number of individuals, not so much Medicare and Medicaid, looking at what we do.
