Question

Subject: Health Information Management Technology

QUESTION: Define fraud and abuse. Recommend strategies that can be used to combat fraud and abuse in coding.

Answer 1

Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit.

Examples of healthcare fraud are:

- Misrepresentation of the type or level of service provided;

- Misrepresentation of the individual rendering service;

- Billing for items and services that have not been rendered;

- Billing for services that have not been properly documented;

- Billing for items and services that are not medically necessary;

- Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);

- Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding).

- Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

Fraud and Abuse Prevention Strategies

-Make sure that all coding staff have been properly trained and receive ongoing continuing education.

- Develop comprehensive internal policies and procedures for coding and billing and make sure these written procedures are kept up-to-date. Provide training with regular refresher courses to staff. Conduct random, periodic reviews to make sure procedures are being followed. Keep records of these reviews and their conclusions. Establish mechanisms for all staff to be updated on changes before the effective date of the change. Keep records of all staff in-services, including signatures of staff members acknowledging their participation in the training session and their understanding of the policies and procedures. If you disseminate a memo describing a revised policy or procedure change, ask staff to sign the memo acknowledging their receipt of the information. Keep the memo and the staff signatures on file.

-Monitor coding accuracy through quality audits. Use these audits to identify gaps in knowledge or weak areas and provide appropriate training.

-Evaluate your internal coding practices, and assure they are consistent with coding rules and guidelines. Many facilities have developed facility-specific coding guidelines, which is fine as long as they don't conflict with the official guidelines. Official coding guidelines take precedence over any other guidelines.

-Compare diagnosis codes with procedure codes for consistency.

-Compare reported diagnosis and procedure codes with documentation in the medical record.

-For Evaluation and Management code assignment, compare the required components of the reported E&M code with the documentation in the medical record to assure the code level assigned is substantiated.

-When documentation deficiencies are identified, educate the physicians on improving their documentation. Emphasize the initial importance of documentation by showing examples of how poor documentation can lead to adverse consequences.

-When clarification or additional information is obtained from the physician for coding purposes, make sure this information is subsequently documented in the medical record. Most coders are familiar with the coding principle of "query the physician" when documentation affecting code assignment is unclear or incomplete. Too often, the physician answers the coder's query verbally (or via a note) and the code is assigned based on this exchange, but the physician never adds the information to the record. Thus, the medical record documentation does not support the code assignment. It is not going to help a fraud investigation to tell an investigator "I asked the physician if it was okay to add a code for that condition, and he approved it." The condition must be documented in the medical record.

- Establish a mechanism to assure that memorandums on regulatory issues and provider bulletins are disseminated to all affected staff. The business office is not the only department that needs to know this information. The staff performing the coding and billing functions, not just managerial staff, need to receive this information.

- Do not automatically implement a coding or billing practice simply because a consultant or seminar instructor recommends it. The title of "consultant" or "instructor" does not necessarily make this person more of an "expert" than you. And while there are plenty of reputable firms, there are also some not-so-reputable ones. Verify that the recommendation does not conflict with current official coding guidelines or payment policy. Keep in mind that any abrupt shift in coding or billing practices could make you a target for a fraud investigation, so it is especially important that your change in practice can be supported.

- Keep up-to-date on government regulations (no easy task!). As new or revised regulations are published, add this information to your coding or billing policy and procedure manual. Maintain an up-to-date index for this manual so information is easily accessible for staff.

-Become familiar with physician and/or hospital billing, (depending on which type you are involved in) patterns of utilization, and norms for claims data. Compare your physician's E&M code usage pattern with other physicians in his specialty in the region, state, or nation. Compare your facility's DRG distribution with national data. Compare closely related DRGs. Do you have a significantly higher percentage of patients assigned to a particular DRG than the national or state average? If so, be particularly concerned if this DRG has a higher weight than most of the other DRGs in its "family." Look into the reasons why so many patients are assigned to this DRG. There may be a perfectly logical explanation, and all the cases assigned to this DRG may be appropriate. However, this statistical aberration may attract the attention of the authorities. If you become the target of an investigation, you will be at an advantage if you have already conducted an investigation and feel confident that nothing will be found wrong with your coding practices.

- Evaluate claims denials and code and DRG changes from the fiscal intermediary and Peer Review Organization. Use this information, such as patterns of errors, as an opportunity to educate staff. Appeal all denials you believe to be inappropriate, even those involving only small amounts of money.

- Examine your organization's data over the past several years. Have there been any significant changes in case mix or coding practices? Any significant increases in the number of patients assigned to some DRGs (particularly DRGs that are higher-weighted than their related DRGs)? Are there reasonable explanations for this shift? Document any explanations. Keep in mind that any sudden changes in patterns can raise a red flag in the minds of the authorities, and fraud investigations can go back several years.

- Make sure your chargemaster is being maintained by someone with knowledge of coding, billing regulations, and medical record documentation.

- If you identify an inappropriate coding or billing practice that could be construed as fraud (i.e., it resulted in overpayments), inform your legal counsel of any adverse implications and let them decide the appropriate course of action. A compliance program to correct the problem and assure it doesn't recur should be implemented at once-before your facility becomes a target of an official fraud investigation.