BHA FPX 4006 Assessment 2

Major Categories of Health Care Fraud and Abuse

Fraud and abuse pose significant challenges in the healthcare sector, impacting taxpayers, cases, and various realities involved. The National Healthcare Anti-Fraud Association (n.d.) reported that in 2018, healthcare charges amounted to 3.6 trillion bones, with a substantial portion allocated to healthcare insurance claims. Unexpectedly, health care fraud and abuse are estimated to bring the United States a stunning 68 billion bones annually (Blue Cross Blue Shield, n.d.). The Federal Bureau of Investigation (FBI) spearheads examinations into fraud and abuse (Health Care Fraud, 2022), while the Office of Inspector General (OIG) oversees governmental oversight, combating fraud, waste, and abuse (Office of Inspector General, n.d.). 

It’s vital to distinguish between fraud and abuse, as outlined by the Centers for Medicare and Medicaid Services (2021). Fraud entails purposeful deception for particular or financial gain (Office of Inspector General, 2018), constantly employing sophisticated ways eased by technological advancements (Schwayder, 2021). In distinction, abuse involves the unhappy or devilish use of resources to deceive or harm, potentially resulting in financial or nonfiscal violations (Office of the Inspector General, n.d.). 

The primary orders of healthcare fraud and abuse encompass phantom billing, billing for absent-reflex violations, upcoding service claims, unbundling combined services, and provision of medically “gratuitous” services (Moseley, 2013). 

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Five Health Care Fraud and Abuse Laws

Civil healthcare programs like Medicaid and Medicare are shielded by laws aimed at combating and preventing fraud and abuse (Centers for Medicare and Medicaid Services, 2021). These laws include the False Claims Act (FCA), the Anti-Reflex Statute (AKS), the Physician Self-Referral Law (STARK Law), the Civil Monetary Penalties Law (CMPL), and the Exclusion Statute (Centers for Medicare and Medicaid Services, 2021). 

The False Claims Act serves as a robust tool against healthcare fraud, guarding the government from fraudulent claims and assessing hefty penalties on violators (Office of Inspector General, 2011). Also, the Anti-Referral Statute criminalizes prevailing for referrals, with penalties including fines, imprisonment, and program rejection (Office of Inspector General, n.d.). 

Physicians are banned from self-referral to designated health services under the STARK Law, which authorizes fines and program rejection for violations (Office of Inspector General, n.d.). Also, the CMPL authorizes civil fiscal penalties for Medicaid and Medicare fraud and abuse, while the Exclusion Statute authorizes rejection from civil healthcare programs for condemned individuals (Office of Inspector General, n.d.). 

Upcoding and the Law

Upcoding, a current form of healthcare fraud, involves billing for more advanced refunding services than those rendered (National Health Care Anti-Fraud Association, n.d.). This deceptive practice violates the False Claims Act and results in overcharging civil programs (Office of Inspector General, n.d.). 

Recent suits illuminate cases of upcoding, analogous to the case against Kaiser Permanente, criminalized by submitting inaccurate law judgments to Medicare Advantage for increased remitments (Payne, 2021). Also, CareWell Urgent Care Center settled FCA claims for overbilling Medicare and Medicaid for gratuitous medical services (PR Newswire, 2019). 

Identifying and Addressing Upcoding in Health Care

Preventing upcoding necessitates compliance with civil healthcare laws and regulations, along with accurate coding, billing, and proper documentation (Office of Inspector General, n.d.). Internal monitoring, auditing, and staff training are vital for ensuring compliance and early discovery of fraudulent practices (Office of Inspector General, n.d.). 

Systems to combat upcoding and other forms of fraud and abuse are essential to conserving trust in healthcare providers and securing civil healthcare programs (Howard, 2020). Reporting suspected fraud and abuse is imperative, with resources analogous to hotlines and governmental websites available for whistleblowers (Office of Inspector General, 2019). 

BHA FPX 4006 Assessment 2 Health Care Fraud and Abuse

Department of Justice. (2019). Three physicians and five marketers were charged for violation of the federal anti-kickback statute. The United States Attorney’s Office, Northern District of Oklahoma. 

Health Care Fraud. (2022). Federal Bureau of Investigation. Retrieved October 16, 2022, from https://www.fbi.gov/how-we-can-help-you/safety-resources/scams-and-safety/commonscams-and-crimes/health-care-fraud

Schwayder, J. (2021). Health care fraud exposed: The penalties of deception can be much worse than medical negligence. Contemporary OB/GYN, 66(7), 30–32.