Investigating Health Care Fraud

Investigations relating to health care fraud activity are reportedly at an all time high, and will continue to flourish with the advent of new working groups, task forces and other fraud-fighting activity that existence depends on the development and investigation of health care fraud cases. Simply put, the investigation of health care fraud consists of proving that the provider engaged in an intentional deception or misrepresentation (of material fact) that resulted, or could have resulted, in an unauthorized payment. Some key facts related to health care fraud investigations:

Complaint Driven: Private, local, state and/or federal agencies are actively involved in the identification and investigation of health care fraud and abuse, which, for the most part, are initiated by complaints received from patients, insurers and others on a health care provider or entity.

Complaint Evaluation: The investigative process starts by the investigator evaluating the information in the complaint to determine if it represents actual misconduct, and then to identify what specific laws, rules, and/or regulations may have been violated. Critical areas to be addressed may include:

oDOCUMENTATION-was the services documented as medically necessary, and completely and accurately documented in the patient’s health care record?

oREGULATORY LAWS & RULES-were the services rendered consistent with the administrative law for the State, including scope of practice, training, supervision and delegation? Additionally, were the services, or the manner in which they were rendered, in violation of prohibited conduct?

oTHIRD PARTY PAYER RULES-were the services rendered consistent with the rules set by the involved third party payer, including those relevant to limitation of services rendered, and those limiting the service provider?

oCODING-were the proper ICD-9 and CPT-4 codes used to identify the condition (s) being treated and the services rendered when seeking reimbursement?

Investigative Plan: The investigator will identify potential witnesses to interview, other needed information, such as patient and insurance claim files that may possess evidence of the misconduct. The successful investigation will result in the collection identify and collect all relevant evidence that would indicate the laws, rules and/or regulations governing health care have been violated, and to identify storytellers who will be able to testify on matters relevant to the identified misconduct. The patient file is the crime scene when investigating health care fraud & abuse.

MAJOR TRENDS IN HEALTH CARE FRAUD

Problem (Multidiscipline Practices): Some multidiscipline practices of medical doctors, chiropractors, and other providers working together in one practice entity are formed by some chiropractors as a means to circumvent managed care and other third party payer limitations on reimbursement of chiropractic services. At times, when necessary, multiple corporations are created to allow the chiropractor to employ medical doctors and to maintain control over all revenues of the multidiscipline practice. The services rendered by the chiropractor in cases where there is little or no chiropractic coverage are billed to the third party payer under the license and name of the medical doctor, purportedly following “Incident-to” billing principles after the medical doctor evaluated the patient and referred them for care with the chiropractor. Is the chiropractor billing for their services rendered under the license of a medical doctor?

Problem (Mobile Labs): Some external companies, or mobile labs, market their electro-diagnostic testing services extensively to health care providers as a means to increase patient retention and increase revenues. The mobile lab provides on-site electro-diagnostic testing on the provider’s patients with their equipment and by their technician. The provider pays the lab a rental fee for the equipment and technician, and agrees to provide a minimum number of patients for testing during one day. The lab bills the third party payer for only the reading of the tests, or the professional component, and the provider bills for administering the tests, or the technical component, because they rented the equipment/technician and supervised its administration. Further, the lab will provide the provider with the CPT codes and amounts that should be reported and billed for the technical portion of the test. The provider, claiming to have supervised the administration of the diagnostic test, may not have the requisite training and skill on the test. Often, the total amount billed (both professional and technical) for the tests will far exceed the RVU (Relative Value Unit) set for these tests. The client provider usually will have no actual knowledge on what the labs will bill to the third party payer. What service did the provider perform to bill for the technical portion?

Problem (Rehab): Some providers implement (active) rehabilitation care into their health care practices by having their unlicensed staff administer therapeutic procedures to patients that are defined as one-on-one with the patient by a licensed provider, and are reported in 15-minute increments. Documentation of medical necessity of therapeutic procedures may not be properly established in the patient’s clinical record as part of a treatment plan. Documentation of procedures in file, even when directly provided by licensed provider, may not be properly documented to account for the time component of the service, i.e., Start & End time, which includes pre-intra-post service time. Is the provider’s unlicensed staff rendering the rehab services to the patients of the practice? What does the patient’s health care record show? Do they support the need and accuracy of the billings?

Problem (Billing): Various insurance companies have limitations on what health care conditions and services they will reimburse providers for. Some providers provide their patients with health care services that are not reimbursable by the involved managed care organization or third party payer, but report and bill for these services via use of ICD-9 and CPT-4 codes that are reimbursable. Some providers provide their patients with various health care services based solely on the premise that the involved managed care organization or third party payer will reimburse for those services.

Problem (Solicitation): A number of providers market “free” services, such as consults, exams and x-rays to attract new patients that may not be established as medically necessary, or will later be billed to a third party payer. A number of providers’ market “free” services, such as therapeutic massage, as a means to attract new patients to the health care practice, which later may become a part of the patient’s billed care. A number of providers inform marketed individuals when converting them to patients that they will not be responsible for what the insurance company does not pay. For the health care provider what is a consult? Isn’t it a history? Was the promised free service, or a portion of it, later billed? Is it possible to give away a therapeutic massage without first examining the patient to establish need?

Hurried, Corrupt and Evil Health Care Reform

As a concerned American citizen, I feel compelled at this time to express some strong personal convictions about what is happening in the United States right now with health care reform. In recent months and especially in the last few weeks, this has swelled into a big issue, almost rivaling the economic crisis in media attention and in many Americans’ minds. Why?

Well, for one thing, everyone recognizes that the U.S. health care system is in dire need of reform (and frankly, just about every other system in this country run by the federal government is in the same boat). The percentage of Americans who lack health insurance has grown substantially in recent years, medical costs have skyrocketed, and many people are not getting the health care they need. Health care is a complex multifaceted issue that involves both the public and private sectors and directly affects all Americans sooner or later. Thus, reform of this system is a big project likely to draw wide attention.

But more than that, health care reform is in the spotlight right now because the administration of President Barack Obama has made it a priority. “Health care reform can not wait, it must not wait, and it will not wait another year,” as President Obama famously declared near the middle of his first year in office. The president has been pushing Congress to quickly pass new legislation that would, with his signature, supposedly deliver better and more accessible health care to the American people.

I have to wonder, though: Why such a rush to health care reform? You can’t fix a broken system overnight, whether it’s the economy or health care. Reform is a major undertaking that requires careful research and accurate analysis of the situation, together with a generous period of honest public discussion and debate concerning short-term, medium-term and long-term measures that should be taken to correctly address the situation. Moreover, these elements of reform need the foundation of common moral and ethical guiding principles.

None of these requirements are being met in the current rush to draft and pass health care bills. As a result, U.S. health care reform is on the road to disaster.

So again, why this hurried effort by the Obama administration to enact health care reform? The administration has its reasons for hurrying. One is that they have a semi-secret agenda to accomplish, and this agenda collides head-on with the will of the American people. Whether the mainstream media will acknowledge it or not, there is in fact a fundamental issue even more important to Americans than the twin heavyweights of economic recovery and quality health care. That issue is the right to life of every human being, especially the most innocent and defenseless–the unborn child in the womb.

In Washington, health care reform is being touted merely as a ruse. It serves as a convenient vehicle to advance the Obama administration’s ever more urgent hidden agenda. That agenda is to increase federal funding of, and expand public access to, abortion. And this is the most important reason why health care reform has drawn the scrutiny of Americans right now.

The urgency of this semi-secret agenda from the viewpoint of its proponents becomes clear when we look at trends in recent years. Since 1993, the annual number of abortions and abortion providers in the United States has been in steady decline. U.S. voters across this country (a majority of whom are women) have built and continue to support a vast infrastructure of state restrictions on abortion, from parental notification laws to bans on state funding for abortions to sonogram viewing and waiting period requirements for pregnant girls prior to their scheduled abortion procedure. These laws, together with adoption, crisis pregnancy care centers and various outreach programs, have been wonderfully beneficial for women, for their unborn children and for society itself. Meanwhile, polls have confirmed that an increasing percentage of American citizens oppose the legalization of abortion through the Roe v. Wade Supreme Court decision of 1973. As of this writing, survey reports indicate that a majority of the American people are pro-life.

However, in Congress the overall trend with abortion has been moving in the opposite direction, especially since a Democratic majority came to power in 2006 in the House and Senate. In 2007 Representative Jerry Nadler and Senator Barbara Boxer introduced an infamous joint resolution deceptively named the Freedom of Choice Act (FOCA). The contents of this revolting abortion bill are so evil and frightening that it could only have come straight from Hell and been conceived by the Devil himself. It would have, at one stroke, demolished all state restrictions on abortion. Moreover, this draconian bill would have far surpassed Roe v. Wade in elevating abortion to the status of a “fundamental human right” subject to unlimited government funding and support. Apparently our Congressional representatives intended to remove every legal barrier and provide every possible incentive for Americans to murder their offspring.

So a rift has opened up between the American people and their federal government on the issue of abortion, and in the past few years this rift has been growing increasingly wider. The Obama administration may have given up on FOCA due to massive public opposition (thank God), but it is still bound and determined to enact at least some of FOCA’s provisions into law-for example, the sickening concept of “abortion coverage” as a “health benefit”-whether the American people support them or not.

And what is driving this wicked agenda to ram abortion down our throats? The answer is money. Abortion is still a big, $100 million-per-year business that makes a handful of doctors and companies in the U.S. quite wealthy. But with the gradual nationwide decline in demand for killing “services” and a fervent pro-life ethic among the younger generation of Americans, abortion providers face the real threat of going out of business altogether sometime within the next decade or two. Thus to salvage a sinking enterprise, the multimillion-dollar abortion industry has turned to the rich and powerful federal government for a hand–just as the financial institutions have turned to the same government for rescue from annihilation since late last year. In both cases, the government has generously responded with legislation and fiat money. This administration is not serving our interests but the interests of rich and powerful lobby groups on Capitol Hill. In my estimation, the Obama administration is the most corrupt administration in American history.

This is another reason for the race to health care reform: President Obama and his cronies don’t want Americans to find out the truth behind their new health care policies. In a democracy, corruption has to hurry or else it can’t achieve its ends. Too much research, analysis, discussion and debate-essential for proper reform and healthy for democracy-would expose this corrupt agenda and result in its doom. The “hurried” and “evil” aspects of health care reform both result from the driving force of corruption. Transparency and accountability are crucial for the correct functioning of democracy, yet little of either is evident with our government’s rapidly coalescing health care plan.

So given the divergence between American respect for life on the one hand and governmental obsession with death on the other, our leaders are forced to pretend that they are representing the wishes of the people while they pursue an agenda contrary to those wishes. How long they can keep up this charade remains to be seen in these uncertain and unpredictable times. However, a few things are certain. The American people want affordable health care reform that respects life. Their elected representatives want a health care plan that pads their own pockets and funds murder. Sooner or later, either the abortion industry or its puppet government or both will cave in. But the pro-life movement in this country is strong, it is steadily advancing, and it is destined to win.