Definition of Fraud
Making false statements or misrepresentations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. It is the intentional deception or misrepresentation that an individual knows to be false, or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to them or some other person.
Examples
Improper Billing
· Billing for services not furnished
· Billing for a higher dollar service than what was provided (upcoding)
· Claiming services or items not authorized by a physician
· Claiming services or items which are not medically necessary
· Billing for a related party transaction as if they were provided by
a non-related entity
· Billing for non-related personnel costs (vacation, automobile, home
repairs)
· Gang visits by one or more medical professionals who visit large numbers
of residents in a single day
· Frequent and recurring routine visits by the same medical professional
· Unusually active presence in nursing facilities by health care professionals
who are given or request unlimited access to residents' medical records (the
OIG indicated that these individuals may be collecting information for use in
submitting false claims)
· Misrepresenting a diagnosis in order to get a higher payment rate
· Unbundling (billing for services individually when they should be billed
as a group)
Falsifying records
· Falsely indicating that a service was medically necessary
· Falsifying records such as certificates of medical necessity, plans
of treatment, or medical records
· Creating fictitious payrolls
Cost report issues
· Incorrect apportioning of costs
· Including costs of non-covered services, supplies, or equipment in
allowable costs
· Arrangements by providers with employees, independent contractors,
suppliers, and others that appear to be designed primarily to overcharge the
program through various devices (commissions, fee-splitting) to siphon off or
conceal illegal profits
· Billing Medicare for costs not incurred or which are attributable to
non-program activities, other enterprises, or personal expenses of principals
· Repeatedly including unallowable cost items, except for the purpose
of establishing a basis for appeal
· Manipulation of statistics to obtain additional payment such as increasing
square footage in the outpatient areas to maximize payment
· Claiming bad debts without first genuinely attempting to collect payments
· Certain hospital based physician arrangements and amounts actually
paid to physicians
· Amounts paid to owners or administrators that have been determined
to be excessive in prior cost report settlements
· Days that have been improperly reported and would result in an overpayment
if not adjusted
· Depreciation for assets that have been fully depreciated or sold
· Depreciation methods not approved by Medicare
· Program data where provider program amounts cannot be supported
· Including costs for donations, gifts, entertainment, alcoholic beverages,
and personal use of private vehicles for reimbursement through the Medicare
cost report
· Improper allocation of costs to related organizations that have been
determined to be improper
· Accounting manipulations
· Abuse of internal accounting controls by administrative personnel