Transcript Identifying SoonerCare False Claims, Fraud and Abuse

Identifying SoonerCare
False Claims, Fraud and
Abuse
Course Introduction
12/01/2014 Version 1.01
Pre-Assessment
Recently, Betty has noticed that Debra has
been putting copies of billing records in an
envelope in her desk drawer. Today Debra
put the envelope in her purse and left
quickly for lunch. After she returned, Betty
saw her counting a large sum of money and
putting it in her billfold.
Betty thinks Debra might be selling
SoonerCare provider numbers.
Course Introduction
Betty and Debra have been co-workers at a
large medical billing office for several years.
Debra has confided to Betty that she has
been having some major financial problems.
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Pre-Assessment
Could Debra’s actions in this scenario
indicate SoonerCare fraud?
If you knew SoonerCare fraud or abuse
was occurring would you know how
and what to report?
Would you lose your job if you
reported this incident?
Course Introduction
Do you know the difference between
SoonerCare fraud and SoonerCare
abuse?
3
Introduction
The Oklahoma Health Care Authority and the federal
government are aggressively dealing with these issues
and are asking for your help as an OHCA employee,
employee of another state agency involved in SoonerCare
services, or as a contractor in identifying fraud and abuse
incidents or other inappropriate payments.
Course Introduction
Billions of taxpayer dollars
are lost every year to health
care fraud and abuse. An
estimated 10% of national
Medicaid costs are
inappropriately spent on
fraud and abuse incidents.
4
Introduction
The Act mandates that any entity which receives at least $5
million in Medicaid payments per year must implement
employee education programs and certain written policies
related to the detection and prevention of Medicaid fraud and
abuse.
Course Introduction
The passage of the Deficit
Reduction Act (DRA) of 2005
has made Medicaid Fraud and
Abuse compliance programs
mandatory for many
organizations.
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Course Objectives
This course will educate you about identifying SoonerCare fraud
and abuse. This education will help you protect yourself against
accusations of fraud and abuse.
Course Introduction
SoonerCare is the name most commonly associated with the
Medicaid program in Oklahoma. In this course we will be using
the terms interchangeably.
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Course Objectives
The first lesson in this course is an:
 Introduction to SoonerCare fraud and abuse




Identifying fraud and abuse
Liability and penalties for fraud and abuse
How to safeguard against fraud and abuse
How to report suspected fraud and abuse
Before you begin the first module take just a few minutes to complete
the Pre-Assessment. It will help us identify what you already know
about SoonerCare fraud and abuse.
Course Introduction
Other lessons include:
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Identifying SoonerCare
False Claims, Fraud and
Abuse
Pre-Assessment
12/01/2014 Version 1.01
Introduction
Pre-Assessment
This Pre-Assessment consists of 15 questions.
 The purpose of the Pre- and Post-Assessments is to simply let
you see what you currently know concerning SoonerCare
fraud and abuse.
 After completing the Pre-Assessment, you will proceed to
Module 1, Introduction to SoonerCare Fraud and Abuse.
2
Practice
What is the best definition of SoonerCare
fraud?
B – Knowingly executing a scheme against the SoonerCare program
C – Willfully executing a scheme against the SoonerCare program
D – All of the above
Click the appropriate answer.
Pre-Assessment
A – Attempting a scheme against the SoonerCare program
3
Practice
What is the best definition of SoonerCare
fraud?
The correct answer is D. All are
examples of SoonerCare fraud.
B – Knowingly executing a scheme against the SoonerCare program
C – Willfully executing a scheme against the SoonerCare program
D – All of the above
Pre-Assessment
A – Attempting a scheme against the SoonerCare program
3
Practice
What is the best definition of SoonerCare
abuse?
B – Intentionally violating SoonerCare guidelines
C – Unknowingly violating SoonerCare guidelines
D – None of the above
Click the appropriate answer.
Pre-Assessment
A – Knowingly defrauding the SoonerCare program
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Practice
What is the best definition of SoonerCare
abuse?
The correct answer is C.
SoonerCare abuse is unknowingly
violating SoonerCare guidelines.
B – Intentionally violating SoonerCare guidelines
C – Unknowingly violating SoonerCare guidelines
D – None of the above
Pre-Assessment
A – Knowingly defrauding the SoonerCare program
4
Practice
Pre-Assessment
If a provider charges a patient for a service
that is not covered by SoonerCare, has
fraud or abuse occurred?
A – NO
B – YES
5
Click the appropriate answer.
Practice
The correct answer is NO.
Charging a patient for a service
that is not covered by SoonerCare
does not constitute fraud or
abuse.
A – NO
B – YES
Pre-Assessment
If a provider charges a patient for a service
that is not covered by SoonerCare, has
fraud or abuse occurred?
5
Practice
Pre-Assessment
If someone completes a certificate of
medical necessity without a physician’s
involvement in the care of the patient, has
SoonerCare fraud or abuse occurred?
A – NO
B – YES
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Click the appropriate answer.
Practice
The correct answer is Yes. A
physician’s involvement is
required for a certificate of
medical necessity form.
A – NO
B – YES
Pre-Assessment
If someone completes a certificate of
medical necessity without a physician’s
involvement in the care of the patient, has
SoonerCare fraud or abuse occurred?
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Practice
Pre-Assessment
A provider collects more than the
established co-payment amounts from a
patient for medical treatment. Has
SoonerCare fraud or abuse occurred?
A – NO
B – YES
7
Click the appropriate answer.
Practice
The correct answer is Yes.
SoonerCare providers are not
allowed to collect more than the
established co-payment.
A – NO
B – YES
Pre-Assessment
A provider collects more than the
established co-payment amounts from a
patient for medical treatment. Has
SoonerCare fraud or abuse occurred?
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Practice
B - Abuse
Pre-Assessment
A SoonerCare provider requires a deposit
from a SoonerCare member as a condition
for continued care. Is this violation fraud,
abuse, or neither?
C - Neither
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A - Fraud
Click the appropriate answer.
Practice
A SoonerCare provider requires a deposit
from a SoonerCare member as a condition
for continued care. Is this violation fraud,
abuse,
neither?answer is A. A provider
Theorcorrect
B - Abuse
Pre-Assessment
that requires a deposit from a
member as a condition for continued
care has committed fraud.
C - Neither
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A - Fraud
Practice
B - Abuse
Pre-Assessment
A provider intentionally upcodes services to
a higher level in order to receive a larger
reimbursement from SoonerCare. Is this
violation fraud, abuse, or neither?
C - Neither
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A - Fraud
Click the appropriate answer.
Practice
A provider intentionally upcodes services to
a higher level in order to receive a larger
reimbursement from SoonerCare. Is this
violation
abuse,
or neither?
The fraud,
correct
answer
is A. Upcoding
B - Abuse
Pre-Assessment
services to a higher level to receive a
larger SoonerCare reimbursement is
an example of fraud.
C - Neither
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A - Fraud
Practice
Pre-Assessment
Are providers financially liable if their billing
services commit fraud without the
provider’s knowledge?
A – NO
B – YES
10
Click the appropriate answer.
Practice
The correct answer is Yes.
Providers are financially liable if
their billing services commit
fraud, even without the provider’s
knowledge.
A – NO
B – YES
Pre-Assessment
Are providers financially liable if their billing
services commit fraud without the
provider’s knowledge?
10
Practice
Pre-Assessment
Are providers financially liable for all claims
submitted on their behalf that contain their
SoonerCare identification number?
A – NO
B – YES
11
Click the appropriate answer.
Practice
The correct answer is Yes. Providers
are financially liable for all claims
submitted on their behalf that contain
their SoonerCare identification
number.
A – NO
B – YES
Pre-Assessment
Are providers financially liable for all claims
submitted on their behalf that contain their
SoonerCare identification number?
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Practice
Which of the following penalties can occur
if you are liable for SoonerCare abuse?
B – Your assignment privileges can be revoked.
C – You can be imprisoned
D – All of the above
Click the appropriate answer.
Pre-Assessment
A – You can be obligated to participate in provider education initiatives.
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Practice
Which of the following penalties can occur
if you are liable for SoonerCare abuse?
The correct answer is D. All are
penalties that can occur if you are
suspected of SoonerCare abuse.
B – Your assignment privileges can be revoked.
C – You can be imprisoned
D – All of the above
Pre-Assessment
A – You can be obligated to participate in provider education initiatives.
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Practice
A – Ensure that your SoonerCare provider number is noted on all
documents for all staff to see so that they can verify your
SoonerCare provider status.
B – Make sure SoonerCare guidelines and updates are regularly
circulated among appropriate claim and billing staff and
implemented in your systems.
C – Make sure that a Waiver of Liability is being provided to patients for
all services performed.
D – Assume that all employees or providers hired or contracted with are
not on the Sanctioned Provider List.
Click the appropriate answer.
Pre-Assessment
When implementing safeguards to prevent
SoonerCare fraud and abuse, you should
keep which of the following in mind?
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Practice
A – Ensure that your SoonerCare provider number is noted on all
documents for all staff to see so that they can verify your
SoonerCare provider status.
B – Make sure SoonerCare guidelines and updates are regularly
circulated among appropriate claim and billing staff and
implemented in your systems.
C – Make sure that a Waiver of Liability is being provided to patients for
all services performed.
D – Assume that all employees or providers hired or contracted with are
not on the Sanctioned Provider List.
Pre-Assessment
The correct answer is B. When implementing safeguards to
preventimplementing
fraud and abuse
you shouldtomake
sure SoonerCare
When
safeguards
prevent
guidelines and updates are regularly circulated among
SoonerCare fraud and abuse, you should
appropriate billing staff and implemented in your systems
keep
of all
theemployees
followingor
inproviders
mind? are not on the
andwhich
confirm
Sanctioned Providers List.
13
Practice
A – Charges for their service on the basis of the number of claims they
file rather than at a single monthly rate
B – Guarantees the confidentiality of your SoonerCare provider number
and other personal information
C – Conducts routine audits of patient charge amounts for services
rendered by the provider
D – All of the above
Click the appropriate answer.
Pre-Assessment
When selecting a billing service to use, you
should choose a service that:
14
Practice
Theselecting
correct aanswer
is D. You
When
billing service
to should
use, youalways
select
a billing
service
that:
should
choose
a service
that:
A – Charges for their service on the basis of the number of claims they
file rather than at a single monthly rate
B – Guarantees the confidentiality of your SoonerCare provider number
and other personal information
C – Conducts routine audits of patient charge amounts for services
rendered by the provider
D – All of the above
Pre-Assessment
• Charges on the basis of the number of claims
filed rather than a monthly rate
• Guarantees confidentiality
• Conducts routine audits of patient charge
amounts for services rendered by the provider
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Practice
To safeguard from fraud and abuse,
providers should choose a laboratory that:
B – Monitors the test request forms to ensure that there is a diagnosis
code defining the reason why each test was ordered
Pre-Assessment
A – Does not change diagnosis codes on the original test request form
C – All of the above
D – None of the above
Click the appropriate answer.
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Practice
The correct
answer
is C.abuse,
When selecting a
To safeguard
from
fraud and
lab, you
should
choose
one thatthat:
does not
providers
should
choose
a laboratory
change diagnosis codes and monitors test
request forms to ensure that there is a
diagnosis code defining the reason each
test was ordered.
B – Monitors the test request forms to ensure that there is a diagnosis
code defining the reason why each test was ordered
Pre-Assessment
A – Does not change diagnosis codes on the original test request form
C – All of the above
D – None of the above
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Practice
What is the term used in the False Claims
Act that refers to a person reporting fraud
and abuse?
Pre-Assessment
A – Singer
B – Tattletale
C – Informant
D – Whistleblower
Click the appropriate answer.
16
Practice
What is the term used in the False Claims
Act that refers to a person reporting fraud
and abuse?
The correct answer is D. The term that is
used in the False Claims Act that refers to
a person reporting fraud and abuse is
whistleblower
B – Tattletale
C – Informant
D – Whistleblower
Pre-Assessment
A – Singer
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Practice
The False Claims Act contains a
whistleblower-protection provision for
persons reporting fraud and abuse. What
does this mean?
A – Persons reporting fraud or abuse may be subject to the same
penalties as the person committing the fraud or abuse.
C – Persons reporting fraud and abuse who are discharged, demoted,
suspended, harassed, or discriminated against have protection from
such actions.
D – Persons reporting fraud and abuse will be guaranteed another
position if they are discharged from their current position.
Click the appropriate answer.
Pre-Assessment
B – Persons reporting fraud or abuse can be discharged or demoted.
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Practice
The False Claims Act contains a
whistleblower-protection provision for
persons reporting fraud and abuse. What
The correct answer is C. Persons who are
does this mean?
C – Persons reporting fraud and abuse who are discharged, demoted,
suspended, harassed, or discriminated against have protection
from such actions.
D – Persons reporting fraud and abuse will be guaranteed another
position if they are discharged from their current position.
Pre-Assessment
discharged, demoted, suspended,
A – Personsor
reporting
fraud or abuse
may befor
subject to the same
harassed,
discriminated
against
penalties
as theor
person
committing
the fraud or abuse.
reporting
fraud
abuse
have protection
from
such actions.
B – Persons
reporting fraud or abuse can be discharged or demoted.
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Congratulations!
Pre-Assessment
You have completed the Pre-Assessment.
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Identifying SoonerCare
False Claims, Fraud and
Abuse
Introduction to SoonerCare Fraud and Abuse
12/01/2014 Version 1.01
Module Objectives
 Define SoonerCare fraud
 Define SoonerCare abuse
Introduction to SoonerCare Fraud and Abuse
After completing this module, you will be able to:
2
Anne Greene, a social worker who is
a contracted SoonerCare Provider,
has a friend, Susan Young, who
works in an inpatient psychiatric
facility.
Once patients are released, Susan
gives their SoonerCare ID numbers
to Anne. Anne bills SoonerCare for
services she never rendered and
splits the proceeds with Susan.
Introduction to SoonerCare Fraud and Abuse
Scenario
3
Scenario
How do you know the difference?
Introduction to SoonerCare Fraud and Abuse
Are Anne and Susan committing
SoonerCare fraud or was it abuse?
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So that you can be vigilant against
fraud and abuse, you need to
understand the legal definitions of
each.
Medicaid fraud is legally defined as:
Knowingly and willfully executing, or attempting to execute, a
scheme or artifice to defraud any health care benefit program or
to obtain, by means of false or fraudulent pretenses,
representation, or promises, any of the money or property owned
by or under the custody of any health care benefit program.
Introduction to SoonerCare Fraud and Abuse
Definition of SoonerCare Fraud
5
Definition of SoonerCare Fraud
A health care provider may be considered to have committed
fraud if they self-identify inappropriate actions or behavior against
the SoonerCare program and do not report those actions to the
OHCA and do not take steps to
remedy them.
All health care providers who
participate in the program furnish and
report services in accordance with
SoonerCare regulations and policies.
Introduction to SoonerCare Fraud and Abuse
Individuals who commit fraud intentionally obtain, or attempt to
obtain, money or property through false or fraudulent pretenses.
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Now that you know the definition, was
fraud committed against SoonerCare in the
scenario involving the social worker, Anne
Greene, and her friend Susan Young?
A – NO
B – YES
Introduction to SoonerCare Fraud and Abuse
Scenario
7
Click the appropriate answer.
Now that you know the definition, was
fraud committed against SoonerCare in the
scenario The
involving
the answer
social worker,
correct
is Yes.Anne
This
Greene, and
her friend
Young? of
scenario
is a Susan
good example
fraud. Anne and Susan knowingly
and willfully executed a scheme
to defraud SoonerCare.
A – NO
B – YES
Introduction to SoonerCare Fraud and Abuse
Scenario
7
Scenario
Two billing coders work for a doctor who is a SoonerCare
provider. Pamela is new to her job and asks the more
experienced coder, Jerry, what code to bill for a venipuncture.
Jerry is distracted by other duties and replies with one of the
most common codes. However, in this case the code that Jerry
provides is wrong. The result is an overcharge to SoonerCare
for a procedure that was not performed.
Introduction to SoonerCare Fraud and Abuse
Now let’s look at
another scenario.
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Scenario
Introduction to SoonerCare Fraud and Abuse
Does this scenario indicate fraud?
A – NO
B – YES
9
Click the appropriate answer.
The correct answer is No.
 Does thisRemember
scenario indicate
fraud?
that by
definition,
fraud is when a person willfully
and intentionally obtains, or
attempts to obtain, money or
property through false or
fraudulent pretenses. This
scenario is an example of abuse.
A – NO
B – YES
Introduction to SoonerCare Fraud and Abuse
Scenario
9
Definition of SoonerCare Abuse
Obtaining payment for items or
services when there is no legal
entitlement to that payment, but the
person did not knowingly or
intentionally misrepresent facts to
obtain payment.
These actions usually result, directly or
indirectly, in unnecessary costs to the
SoonerCare program. They may also lead
to improper payment, services that fail
to meet professionally recognized
standards of care, or services that are
medically unnecessary.
Introduction to SoonerCare Fraud and Abuse
Medicaid abuse is legally defined as:
10
Individuals who are responsible for SoonerCare abuse
unintentionally follow practices that violate the guidelines of
the SoonerCare program which may result in unnecessary
costs.
Introduction to SoonerCare Fraud and Abuse
Definition of SoonerCare Abuse
11
It is often difficult to judge the difference
between fraud and abuse. Ultimately, in
Oklahoma the Attorney General’s Office
Medicaid Fraud Control Unit makes this
determination.
SoonerCare contractors and providers are
responsible for correcting any billing or
reporting errors that are identified. If the
errors result in overpayments, the contractor
is required to return the overpaid amounts
to SoonerCare.
The Office of Inspector General within
OKDHS makes fraud and abuse
determinations for SoonerCare members.
Introduction to SoonerCare Fraud and Abuse
Definition of SoonerCare Abuse
12
Module Summary
You learned the legal definitions for fraud and abuse and saw
some examples of each in the scenarios.
Remember that the main difference between fraud and abuse is
that fraud is knowingly and willfully executing a scheme or
artifice to defraud any health care benefit program.
Abuse is when payment is obtained for items or services but the
person did not knowingly or intentionally misrepresent facts to
obtain payment.
Introduction to SoonerCare Fraud and Abuse
You have completed Module 3 – Introduction to SoonerCare
Fraud and Abuse.
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Identifying SoonerCare
False Claims, Fraud and
Abuse
How to Identify Medicaid Fraud and Abuse
12/01/2014 Version 1.01
Objectives
 Recognize the most common types of SoonerCare fraud
 Recognize the most common types of SoonerCare abuse
How to Identify Medicaid Fraud and Abuse
After completing this module, you will be able to:
2
Introduction
The scenarios on the next few frames are based on cases that have
recently occurred involving SoonerCare claims. They will give you a
chance to think about the differences between fraud and abuse. The
distinction might not be as easy as you would think.
After the scenarios you’ll learn about some of the most common types
of SoonerCare fraud and how to be aware of them.
How to Identify Medicaid Fraud and Abuse
Being able to accurately recognize fraud and abuse is one of the first
steps to preventing it.
3
Tom Fontana, a physical therapist, sets an
appointment to see a SoonerCare member.
The member does not show up at the
appointment. Tom is upset because he held
the time open for the member. He bills
SoonerCare for the session anyway because
he has overhead to cover.
Which of the following do you think
occurred in this scenario?
A – FRAUD
B – ABUSE
How to Identify Medicaid Fraud and Abuse
Scenario
4
Click the appropriate answer.
Tom Fontana, a physical therapist, sets an
appointment to see a SoonerCare member.
The member does not show up at the
The correct answer is Fraud. Tom
appointment. Tom is upset because he held
has
committed
SoonerCare
fraud.
the time
open
for the member.
He bills
The services
were anyway
not performed
SoonerCare
for the session
because
he has overhead
to cover.was billed for the
but SoonerCare
services. Tom is intentionally
Which of submitting
the following
you thinkclaim.
a do
fraudulent
occurred in this scenario?
A – FRAUD
B – ABUSE
How to Identify Medicaid Fraud and Abuse
Scenario
4
Dr. Samuelson sees a SoonerCare member
and fills out paperwork but fails to code the
level of care. His office manager mistakenly
entered the wrong level of service on his
behalf.
Which of the following do you think
occurred in this scenario?
A – FRAUD
B – ABUSE
How to Identify Medicaid Fraud and Abuse
Scenario
5
Click the appropriate answer.
Dr. Samuelson sees a SoonerCare member
and fills out paperwork but fails to code the
level of The
care.correct
His office
manager
mistakenly
answer
is Abuse.
The
entereddoctor
the wrong
of service
onso
histhe
did level
see the
patient
behalf. service was performed but it was
billed with a wrong level of
Which of the following
do you think
service.
occurred in this scenario?
A – FRAUD
B – ABUSE
How to Identify Medicaid Fraud and Abuse
Scenario
5
Common Types of SoonerCare Fraud
Knowingly and willfully executing, or
attempting to execute, a scheme or
artifice to defraud any health care
benefit program or to obtain, by means
of false or fraudulent pretenses,
representation, or promises, any of the
money or property owned by or under
the custody of any health care benefit
program.
How to Identify Medicaid Fraud and Abuse
Remember the definition of Medicaid
fraud from Lesson 1?
6
Common Types of SoonerCare Fraud
A mother brings her daughter to the doctor because she suspects that
she broke a bone falling out of a tree. However, the doctor realizes the
bone is not broken and sends the child on her way with a sling. The
doctor bills SoonerCare for an x-ray that was not performed.
Common Types of Fraud
Billing for services that were not rendered
How to Identify Medicaid Fraud and Abuse
One of the most common types of SoonerCare fraud is billing for
services that were not performed.
7
Here is an example of abuse by misrepresentation. An obstetrician is seeing a
pregnant patient. At one of her regular visits she becomes insistent that she
have another ultrasound so she can tell people whether to buy pink or blue
clothes for the baby. Even though this ultrasound is not medically necessary,
the doctor decides to give it to her to make her happy.
Since this ultrasound is not a covered service, the doctor bills SoonerCare for
IV treatment for dehydration which was not given to the patient.
Common Types of Fraud
Misrepresenting as medically necessary non-covered or
screening services by reporting covered procedure or revenue
codes
How to Identify Medicaid Fraud and Abuse
Common Types of SoonerCare Fraud
8
Common Types of SoonerCare Fraud
A group of nursing home patients were offered free exercise and social
activities. However, the free services were billed to SoonerCare as
covered Partial Hospitalization services at a Community Health Center
or as covered physical therapy at a rehabilitation facility.
Common Types of Fraud
Misrepresenting as medically necessary non-covered or
screening services by reporting covered procedure or revenue
codes
How to Identify Medicaid Fraud and Abuse
This can be tricky. Here is another example of fraud and abuse by
misrepresentation:
9
Common Types of SoonerCare Fraud
Following are two examples of this type of SoonerCare
fraud.
Common Types of Fraud
Signing blank records or certification forms, or falsifying
information on records or certification forms for the sole
purpose of obtaining payment
How to Identify Medicaid Fraud and Abuse
Another serious offense is signing blank records so that
they can be fraudulently completed at a later date.
10
Common Types of SoonerCare Fraud
 A durable medical equipment (DME) supplier has a financial arrangement with
a physician who completes Certificates of Medical Necessity (CMN) for
patients he has never treated. The completed CMNs are used to falsely
document the medical necessity of equipment given to patients who do not
need the equipment.
 Both the physician and the durable medical equipment company are
committing SoonerCare fraud.
 In addition, they are in direct violation of the Anti-kickback Statutes, along
with other various laws.
Common Types of Fraud
Signing blank records or certification forms, or falsifying
information on records or certification forms for the sole
purpose of obtaining payment
How to Identify Medicaid Fraud and Abuse
Durable Medical Equipment Supplier
11
Common Types of SoonerCare Fraud
 A physician signs blank certification forms for a home health agency. Later
that agency uses the forms to falsely represent that skilled nursing services
are needed for patients who would not have qualified for home health
services without a physician’s certification.
 The physician is committing fraud by signing incomplete or blank
certification forms. The home health agency is committing fraud by filing
false claims for the purpose of obtaining SoonerCare payment.
 Both would also be in violation of Anti-kickback Statutes and other laws.
Common Types of Fraud
Signing blank records or certification forms, or falsifying
information on records or certification forms for the sole
purpose of obtaining payment
How to Identify Medicaid Fraud and Abuse
Physician
12
Common Types of SoonerCare Fraud
Common Types of Fraud
Intentionally using procedure/revenue codes that describe
more extensive services than those actually performed
How to Identify Medicaid Fraud and Abuse
Using the incorrect codes is as fraudulent as billing for services
that were not rendered.
13
Common Types of SoonerCare Fraud
 A physician was routinely billing using high-level evaluation and management (E&M)
service procedure codes (upcoding), although many of the visits he furnished did not
meet the requirements for the codes reported.
 This doctor committed SoonerCare fraud when he upcoded the service performed to
a high-level office visit.
Common Types of Fraud
Intentionally using procedure/revenue codes that describe
more extensive services than those actually performed
How to Identify Medicaid Fraud and Abuse
Using the incorrect codes is as fraudulent as billing for services
that were not rendered.
13
Common Types of SoonerCare Fraud
 A hospital falsely reported bacterial pneumonia versus viral pneumonia as the
diagnosis for a majority of the inpatient hospital stays billed to SoonerCare. As a result
the hospital’s diagnosis-related group DRG payment was significantly higher than it
should have been.
 The hospital committed fraud by misrepresenting the diagnosis on its claims.
Common Types of Fraud
Intentionally using procedure/revenue codes that describe
more extensive services than those actually performed
How to Identify Medicaid Fraud and Abuse
Using the incorrect codes is as fraudulent as billing for services
that were not rendered.
13
Practice
Which of the following scenarios describes
upcoding?
A – A radiologist routinely bills for chest x-rays with two views, although
most of the chest x-rays performed are for single views.
B – A physician uses a non-qualified practitioner to perform follow-up
visits but bills as though the physician rendered the services.
C – A fictitious provider bills for services that were never furnished.
How to Identify Medicaid Fraud and Abuse
Now see if you can spot examples of these
types of fraud.
14
Click the appropriate answer.
Practice
of these describe fraud, upcoding
occurs when revenue codes are
Which of the following scenarios describes
upcoding? used that describe more
extensive services than those
actually performed.
A – A radiologist routinely bills for chest x-rays with two views,
although most of the chest x-rays performed are for single views.
B – A physician uses a non-qualified practitioner to perform follow-up
visits but bills as though the physician rendered the services.
C – A fictitious provider bills for services that were never furnished.
How to Identify Medicaid Fraud and Abuse
Now see if you can spot examples of these
correct answer is A. While all
types ofThe
fraud.
14
Practice
A – A home health agency bills for covered home health services for an
unqualified patient.
B – An ambulance company bills for emergency transportation for
scheduled trips from a nursing home to a clinic.
C – A physician falsifies the diagnosis for a service that would otherwise
be denied coverage if it were correctly reported.
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Which of the following describes a provider
misrepresenting as medically necessary
non-covered or screening services?
15
Practice
service as medically necessary
that would not have otherwise
been covered.
A – A home health agency bills for covered home health services for an
unqualified patient.
B – An ambulance company bills for emergency transportation for
scheduled trips from a nursing home to a clinic.
C – A physician falsifies the diagnosis for a service that would
otherwise be denied coverage if it were correctly reported.
How to Identify Medicaid Fraud and Abuse
Which of the following describes a provider
The correct
answer
is C. The
misrepresenting
as medically
necessary
physician
misrepresented
non-covered
or screening
services? the
15
Practice
A – Services or items furnished to a patient but not billed to SoonerCare
B – Non-covered services under SoonerCare
C – Services or items not furnished to a patient but billed to SoonerCare
D – None of the above
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Which of the definitions below best
describes non-rendered services?
16
Practice
The correct answer is C. Nonrendered services are items or
services not furnished to a patient
but billed to SoonerCare.
A – Services or items furnished to a patient but not billed to SoonerCare
B – Non-covered services under SoonerCare
C – Services or items not furnished to a patient but billed to
SoonerCare
D – None of the above
How to Identify Medicaid Fraud and Abuse
Which of the definitions below best
describes non-rendered services?
16
A physician signed a blank medical necessity
certification for a supply company so that the supply
company could bill and be paid for durable medical
equipment that was falsely documented.
Which type of SoonerCare fraud has been
committed by the provider in the scenario?
A – Consistently using procedure/revenue codes that describe more
extensive services than those actually performed
B – Signing, falsifying, or misrepresenting information on records or
certification forms for the sole purpose of obtaining payment
C – Billing for services that were not rendered
D – None of the above
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Practice
17
A physician signed a blank medical necessity
The correct
answer
is B. The
physician
certification
for a supply
company
so that
the supply
signed
andbill
falsified
information
the
company
could
and be paid
for durablefor
medical
equipment
that wasoffalsely
documented.
sole purpose
obtaining
payment. This
allowed the equipment company to bill for
Which type
of SoonerCare
fraud has
been
non-covered
durable
equipment.
committed by the provider in the scenario?
A – Consistently using procedure/revenue codes that describe more
extensive services than those actually performed
B – Signing, falsifying, or misrepresenting information on records or
certification forms for the sole purpose of obtaining payment
C – Billing for services that were not rendered
D – None of the above
How to Identify Medicaid Fraud and Abuse
Practice
17
Other Types of SoonerCare
Fraud




Intentionally using an incorrect provider number
Selling or sharing SoonerCare Medical I.D. cards or numbers
Falsifying information on applications
Offering, accepting, or soliciting bribes, rebates, or kickbacks
How to Identify Medicaid Fraud and Abuse
Here are some other types of SoonerCare fraud to be aware of:
18
A nursing home administrator was paid a referral fee for
allowing a community mental health center
representative to provide free social activities to the
nursing home’s SoonerCare members. Also, the
members were given free meals and shoes for
participating in the activities. However, the free services
were billed to SoonerCare as group psychotherapy.
Which type of fraud occurred in the scenario?
A – Consistently not collecting the co-payment
B – Falsifying information on application, medical records, billing
statements, or cost reports
C – Offering, accepting, or soliciting bribes, kickbacks, or rebates
D – Both B and C
How to Identify Medicaid Fraud and Abuse
Practice
19
Click the appropriate answer.
A nursing home administrator was paid a referral fee for
allowing
a community
mental
health
center
The
correct
answer
is
D. Fraud was
representative to provide free social activities to the
nursing
home’s SoonerCare
members. Also, the
committed
when information
was falsified
members were given free meals and shoes for
for theinfree
services.
The the
administrator
participating
the activities.
However,
free services
were billed to SoonerCare as group psychotherapy.
committed fraud by accepting the referral
Which type of fraud occurredfee.
in the scenario?
A – Consistently not collecting the co-payment
B – Falsifying information on application, medical records, billing
statements, or cost reports
C – Offering, accepting, or soliciting bribes, kickbacks, or rebates
D – Both B and C
How to Identify Medicaid Fraud and Abuse
Practice
19
Now that we have discussed some of
the most common types of
SoonerCare fraud, let’s look at the
various types of abuse.
Remember the definition of abuse is:
Obtaining payment for items or
services when there is no legal
entitlement to that payment but the
person did not knowingly or
intentionally misrepresent facts to
obtain payment.
How to Identify Medicaid Fraud and Abuse
Common Types of SoonerCare Abuse
20
Common Types of SoonerCare Abuse
A nursing home incorrectly closes out their books at the end of the
fiscal year using an accounting method other than Generally Accepted
Accounting Principles (GAAP). This causes a misstatement in their
overall cost per day that is used to establish rates.
Common Types Abuse
Adding inappropriate or incorrect information on cost reports
How to Identify Medicaid Fraud and Abuse
An example of abuse by adding inappropriate or incorrect information
on cost reports:
21
Common Types of SoonerCare Abuse




Electrocardiogram (EKG)
Chest x-ray
Urinalysis
Lab panel
Common Types Abuse
Billing for services or items in excess of those needed by the
patient
How to Identify Medicaid Fraud and Abuse
A hospital has a standard protocol that requires all patients admitted
through the emergency room to have the following tests performed,
regardless of the patient’s condition:
22
Common Types of SoonerCare Abuse
A standard wheelchair with leg rests was furnished to a patient,
however, the supplier accidentally billed SoonerCare for a deluxe
wheelchair with premium leg rests and other accessories.
Common Types Abuse
Upcoding or using procedure or revenue codes that describe
more extensive services than those actually furnished
How to Identify Medicaid Fraud and Abuse
This scenario illustrates upcoding:
23
Common Types of SoonerCare Abuse
A nursing facility reports cable TV, advertising, and penalties expenses
on their cost reports when these items are not allowable.
A facility reports equipment purchases as an expense rather than as an
asset to be depreciated, resulting in an overstatement of their costs.
Common Types Abuse
Including inappropriate or inaccurate information on cost
reports
How to Identify Medicaid Fraud and Abuse
Providers must obtain correct information to avoid inaccurate or
inappropriate information. For example:
24
Common Types of SoonerCare Abuse
Although inappropriate or accidental
billing or reporting may initially appear
abusive, it could evolve into fraud when
mistakes continue to be made with no
monitoring processes in place or when no
effort is made to correct mistakes.
We must all be committed to eliminating
both abuse and fraud so that the
SoonerCare program can provide highquality service to its members.
How to Identify Medicaid Fraud and Abuse
As you’ve seen, there is a very thin line
between abuse and fraud.
25
Practice
Which type of abuse occurred in the following
scenario?
A – Billing for services in excess of those needed by the patient
B – Intentionally or unintentionally filing duplicate claims to the
SoonerCare program, even if it does not result in duplicate payment
C – Collecting more than the allowed co-payment amount from a
member
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
A durable medical equipment supplier delivers
and bills for a wheelchair with several
accessories. However, the physician’s order
required only a standard wheelchair.
26
Practice
wheelchair but a more expensive
Which type of abuse
occurred
in the following
version
was delivered.
scenario?
A – Billing for services in excess of those needed by the patient
B – Intentionally or unintentionally filing duplicate claims to the
SoonerCare program, even if it does not result in duplicate payment
C – Collecting more than the allowed co-payment amount from a
member
How to Identify Medicaid Fraud and Abuse
A durable medical equipment supplier delivers
and bills forThe
a wheelchair
with several
correct answer
is A. The
accessories. However, the physician’s order
physician
ordered
a standard
required only
a standard
wheelchair.
26
Practice
A – Dr. John Slicer billed SoonerCare for a high level E&M visit when a
lower level visit was actually performed
B – Dr. John Slicer pays his billing service to file SoonerCare claims for
him based on the number of claims filed. The billing service often
resubmits claims to SoonerCare which result in a denial letter to the
doctor indicating that claims were denied for duplicate submission.
C – Dr. John Slicer regularly demanded that the SoonerCare patients pay
a $100.00 fee before services could be rendered.
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Which of the scenarios below is an example
of SoonerCare program abuse by upcoding?
27
Practice
occurred when Dr. Slicer billed
SoonerCare for a higher level
E&M when a lower level visit was
performed.
A – Dr. John Slicer billed SoonerCare for a high level E&M visit when a
lower level visit was actually performed
B – Dr. John Slicer pays his billing service to file SoonerCare claims for
him based on the number of claims filed. The billing service often
resubmits claims to SoonerCare which result in a denial letter to the
doctor indicating that claims were denied for duplicate submission.
C – Dr. John Slicer regularly demanded that the SoonerCare patients pay
a $100.00 fee before services could be rendered.
How to Identify Medicaid Fraud and Abuse
Which of the scenarios below is an example
The correct
answer
is by
A. upcoding?
Upcoding
of SoonerCare
program
abuse
27
Which of the following scenarios are
examples of abuse by reporting
inappropriate or incorrect information on
cost reports?
A – Reporting costs that were not incurred or that were attributable to
non-program activities, other enterprises, or personal expenses
B – Using depreciation methods that have not been approved by
SoonerCare
C – Using accounting methods other than Generally Accepted
Accounting Principles (GAAP) to close a facility’s books at the end of
the fiscal year
D – ALL of the above
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Practice
28
Which ofThe
thecorrect
following
scenarios
answer
is D.are
All of
examples
of abuse
by reporting
these
are examples
of abuse by
inappropriate
or incorrect
information
reporting
inappropriate
or on
cost reports?
incorrect information on cost
reports.
A – Reporting costs that were not incurred or that were attributable to
non-program activities, other enterprises, or personal expenses
B – Using depreciation methods that have not been approved by
SoonerCare
C – Using accounting methods other than Generally Accepted
Accounting Principles (GAAP) to close a facility’s books at the end of
the fiscal year
D – ALL of the above
How to Identify Medicaid Fraud and Abuse
Practice
28
Other Types of SoonerCare
Abuse
 Collecting in excess of co-payments
due from a patient
 Requiring a deposit or other payment
from a patient as a condition for
admission, continued care, or other
provision of services
 Unbundling or exploding charges (for
example, reporting a series of codes
when there is one specific code that
describes and includes a payment for
all components of the series of codes)
How to Identify Medicaid Fraud and Abuse
Finally, here are a few more examples of SoonerCare abuse
to be aware of:
29
A SoonerCare member arrives at the emergency
room with a possible broken arm. The
admitting clerk at the hospital tells her she
cannot be treated until her co-payment is paid.
Which type of abuse occurred in the following
scenario?
A – Unbundling or exploding charges
B – Billing for non-covered services
C – Requiring a deposit or other payment from a patient as a condition
for admission, continued care, or other provision of services
Click the appropriate answer.
How to Identify Medicaid Fraud and Abuse
Practice
30
A SoonerCare member arrives at the emergency
correct
answer
C. A
room with aThe
possible
broken
arm.isThe
admitting
clerk atcannot
the hospital
tellsa her
she
provider
require
deposit
cannot be
untilfrom
her co-payment
ortreated
payment
a patient asisapaid.
condition for providing services.
Which type of abuse occurred in the following
scenario?
A – Unbundling or exploding charges
B – Billing for non-covered services
C – Requiring a deposit or other payment from a patient as a condition
for admission, continued care, or other provision of services
How to Identify Medicaid Fraud and Abuse
Practice
30
Summary
 The scenarios used in this module were taken from real
situations and events in which either fraud or abuse occurred.
 After reading the scenarios in this module, you learned to
determine which type of fraud or abuse took place.
How to Identify Medicaid Fraud and Abuse
You have completed Module 4 – How to Identify Medicaid Fraud
and Abuse.
31
Identifying SoonerCare
False Claims, Fraud and
Abuse
Liability and Penalties of Fraud and Abuse
12/01/2014 Version 1.01
Objectives
 Recognize the extent of your liability as a provider for
SoonerCare fraud and abuse
 Identify the criminal and civil penalties imposed on individuals
who are convicted of committing SoonerCare fraud
 Identify the administrative actions SoonerCare contractors
impose on individuals who abuse the SoonerCare program
Liability and Penalties of Fraud and Abuse
After completing this module, you will be able to:
2
As a SoonerCare provider, it is important
to understand your liability risks so you
can protect yourself from SoonerCare
fraud and abuse charges.
Physicians, medical equipment suppliers,
clinical laboratories, other health care
providers, and members may be potential
candidates for putting you at risk.
After you learn about three points of
liability, you will read several real
scenarios in which fraud and/or abuse
was committed.
Liability and Penalties of Fraud and Abuse
Introduction
3
Three Points of Liability
There are three points of liability to keep in mind when considering
your personal liability or your liability as a provider.
1 – Personal Responsibility for Fraud
2 - Personal Responsibility for Abuse
3 - Provider Liability
Liability and Penalties of Fraud and Abuse
How do you know when you would be liable when fraud or abuse is
committed?
4
Three Points of Liability
There are three points of liability to keep in mind when considering
your personal liability or your liability as a provider.
1 – Personal Responsibility for Fraud
2 - Personal Responsibility for Abuse
3 - Provider Liability
Persons are responsible for SoonerCare fraud when the intent to
purposely obtain money or property through false or fraudulent
pretenses has been clearly determined.
Liability and Penalties of Fraud and Abuse
How do you know when you would be liable when fraud or abuse is
committed?
4
Three Points of Liability
There are three points of liability to keep in mind when considering
your personal liability or your liability as a provider.
1 – Personal Responsibility for Fraud
2 - Personal Responsibility for Abuse
3 - Provider Liability
Persons are responsible for SoonerCare abuse for all claims
submitted that violate the SoonerCare program guidelines. This
includes claims submitted by employees, agents, and contractors.
Liability and Penalties of Fraud and Abuse
How do you know when you would be liable when fraud or abuse is
committed?
4
Three Points of Liability
There are three points of liability to keep in mind when considering
your personal liability or your liability as a provider.
1 – Personal Responsibility for Fraud
2 - Personal Responsibility for Abuse
3 - Provider Liability
•
•
SoonerCare contractors and providers may also be held responsible for
fraudulent or abusive claims submitted when they are noted as the
referring physician for the service performed, such as on the claims
submitted by clinical laboratories.
If a provider discovers they received an inappropriate payment for any
reason, they must disclose to OHCA within 60 days, in accordance with
the False Claims Act.
Liability and Penalties of Fraud and Abuse
How do you know when you would be liable when fraud or abuse is
committed?
4
Practice
To give you some practice, read the following three scenarios, then
determine if fraud or abuse was committed and who is responsible.
Aunt Judy took Walter to the doctor’s office and then to Wal-Mart to buy
groceries. Aunt Judy claimed mileage for the entire trip, including the 20
miles extra to go grocery shopping. She claimed that with the price of
gasoline, she needed the money.
A – Aunt Judy is responsible for fraud
B – Walter is responsible for abuse
C – Aunt Judy and Walter are both responsible for fraud
D – Aunt Judy did not do anything wrong
Click the appropriate answer.
Liability and Penalties of Fraud and Abuse
SoonerCare member Walter Jones’ Aunt Judy is contracted under the
Developmental Disabilities Services Waiver as a transportation provider.
5
Practice
To give you some practice, read the following three scenarios, then
determine if fraud or abuse was committed and who is responsible.
The correct answer is A. Aunt Judy is
responsible for fraud because she
knew
extra
miles
totogo
Aunt Judy took
Walterthe
to the20
doctor’s
office
and then
Wal-Mart to buy
groceries. Aunt Judy claimed mileage for the entire trip, including the 20
not
miles extra grocery
to go groceryshopping
shopping. She would
claimed that
withbe
the price of
gasoline, she needed the money.
covered.
A – Aunt Judy is responsible for fraud
B – Walter is responsible for abuse
C – Aunt Judy and Walter are both responsible for fraud
D – Aunt Judy did not do anything wrong
Liability and Penalties of Fraud and Abuse
SoonerCare member Walter Jones’ Aunt Judy is contracted under the
Developmental Disabilities Services Waiver as a transportation provider.
5
Practice
The caseworker, Bob Denver, knows that Edward is eligible for the
Developmental Disabilities Services Waiver, but there is currently a
waiting list for those services. Since he is eligible for coverage anyway,
Bob signs him up for the Advantage Waiver, which currently does not
have a waiting list, even though his disability occurred when he was 15
years old.
Who is responsible and for what?
A – Sara is responsible for fraud
B – Edward is responsible for abuse
C – Bob is responsible for fraud
The Advantage Waiver serves the “frail
elderly” (Oklahomans age 65 years and
older) and adults 21 years of age or older
with physical disabilities who would
otherwise qualify for placement in a
nursing facility. Approximately 14,100
persons receive services through this
Click the appropriate answer.
Liability and Penalties of Fraud and Abuse
Sara Brown goes to her local Department of Human Services Office to
apply for SoonerCare for her son, Edward. She tells the case worker that
Edward, who is now 22, was seriously injured in an automobile accident
at age 15. He is no longer eligible for Sara’s private insurance.
6
Practice
The correct answer is C. Bob is
responsible for fraud because he knew
The caseworker, Bob Denver, knows that Edward is eligible for the
Developmental
Disabilities Services
Waiver, but
therethose
is currently
a
the Advantage
Waiver
is for
who
waiting list for those services. Since he is eligible for coverage anyway,
Bob signsbecame
him up for the
Advantage Waiver,
which currently
does
not
disabled
as adults.
If Sara
and
have a waiting list, even though his disability occurred when he was 15
years old.Edward also knew this, they would be
as well.
Who is responsible andresponsible
for what?
A – Sara is responsible for fraud
B – Edward is responsible for abuse
Liability and Penalties of Fraud and Abuse
Sara Brown goes to her local Department of Human Services Office to
apply for SoonerCare for her son, Edward. She tells the case worker that
Edward, who is now 22, was seriously injured in an automobile accident
at age 15. He is no longer eligible for Sara’s private insurance.
C – Bob is responsible for fraud
6
After reviewing his monthly billing statement from his
contracted billing service, Dr. Anderson notices several
errors, but is too busy to get them corrected. He also
realizes that correcting the errors will result in him
having to repay a large sum of money. Several months
pass and these mistakes continue without correction.
Who is responsible and for what?
A – Dr. Anderson is responsible for abuse since it was not intentional
B – Dr. Anderson is responsible for fraud since he knew about the errors
and did not correct them and did not disclose them within 60 days
Liability and Penalties of Fraud and Abuse
Practice
C – The billing service is responsible for abuse
D – All the above
Click the appropriate answer.
7
After reviewing
his monthly
billing
The correct
answer
is D.statement
Initially from
it his
contracted
billing service,
Anderson
notices
several
was abuse
and theDr.doctor
and
billing
errors, but is too busy to get them corrected. He also
service were responsible. Once Dr.
realizes that correcting the errors will result in him
noted
errors and
didmonths
havingAnderson
to repay a large
sumthe
of money.
Several
notthese
disclose
them
withinwithout
60 days,
it
pass and
mistakes
continue
correction.
becomes fraud.
Who is responsible and for what?
A – Dr. Anderson is responsible for abuse since it was not intentional
B – Dr. Anderson is responsible for fraud since he knew about the errors
and did not correct them and did not disclose them within 60 days
Liability and Penalties of Fraud and Abuse
Practice
C – The billing service is responsible for abuse
D – All the above
7
Practice
A – Claims are submitted that contain mistakes resulting in an
overpayment
B – Claims are submitted in which the provider unintentionally upcoded
charges
C – Claims are submitted that contain mistakes resulting in an
overpayment that the provider identifies, but the provider does not
correct the errors
Click the appropriate answer.
Liability and Penalties of Fraud and Abuse
Which of the following actions may be considered
fraudulent and the provider considered
responsible?
8
Practice
The correct answer is C. Just because a
claim is submitted that contains
mistakes does not mean fraud has been
committed.
A – Claims are submitted that contain mistakes resulting in an
overpayment
B – Claims are submitted in which the provider unintentionally upcoded
charges
C – Claims are submitted that contain mistakes resulting in an
overpayment that the provider identifies, but the provider does not
correct the errors
Liability and Penalties of Fraud and Abuse
Which of the following actions may be considered
fraudulent and the provider considered
responsible?
8
A provider’s actions may be considered
fraudulent or abusive and the provider may be
considered responsible in which of the following
scenarios?
A – A billing service uses the provider’s SoonerCare number to bill for
non-rendered services without the provider knowing it
B – The provider signs blank prescription forms for a medical supply
company so that the company can bill SoonerCare for non-rendered
services
C – The provider receives kickbacks from the company for signing blank
prescription forms
D – All the above
Click the appropriate answer.
Liability and Penalties of Fraud and Abuse
Practice
9
A provider’s actions may be considered
fraudulent
or abusive
and is
the
may be
The correct
answer
D.provider
The provider
considered
in responsible
which of the following
may beresponsible
considered
in all
scenarios?
three scenarios.
A – A billing service uses the provider’s SoonerCare number to bill for
non-rendered services without the provider knowing it
B – The provider signs blank prescription forms for a medical supply
company so that the company can bill SoonerCare for non-rendered
services
C – The provider receives kickbacks from the company for signing blank
prescription forms
D – All the above
Liability and Penalties of Fraud and Abuse
Practice
9
Fraud and Abuse Investigation
The Attorney General’s office Medicaid Fraud
Control Unit and the Office of Inspector
General (OIG) are primarily responsible for
SoonerCare fraud investigations and provide
support to the U.S. Attorney’s Office for cases
that lead to prosecution.
In addition, the OIG coordinates its efforts
with other entities such as the Federal
Bureau of Investigation, the Internal Revenue
Service, OHCA, other state agencies, and
SoonerCare contractors and providers.
Liability and Penalties of Fraud and Abuse
Fraud and abuse are identified and
investigated through a coordinated network
of federal and state agencies and contractors.
10
SoonerCare contractors and
providers participate in the fight
against fraud, waste, and abuse by
referring potential cases of fraud to
law enforcement and by preventing
and detecting fraud and abuse
through education programs like
this one, a review of claims and
cost reports, and coordination with
other organizations.
Liability and Penalties of Fraud and Abuse
Fraud and Abuse Investigation
11
Penalties for Fraud and Abuse
Law enforcement agencies investigating and prosecuting for fraud can
choose between criminal or civil prosecution.
Criminal Penalties vs. Civil Liabilities
 In either case, individuals or entities who have been convicted of
fraud may be excluded from participating in any federal health care
program for a specified period or indefinitely. In addition,
practitioners may have their licenses revoked by the state.
Liability and Penalties of Fraud and Abuse
The penalties for each type differ.
12
Penalties for Fraud and Abuse
Law enforcement agencies investigating and prosecuting for fraud can
choose between criminal or civil prosecution.
Criminal Penalties
Those found guilty may be subject to substantial
penalties, fines, restitution, or imprisonment.
 In either case, individuals or entities who have been convicted of
fraud may be excluded from participating in any federal health care
program for a specified period or indefinitely. In addition,
practitioners may have their licenses revoked by the state.
Liability and Penalties of Fraud and Abuse
The penalties for each type differ.
12
Penalties for Fraud and Abuse
Law enforcement agencies investigating and prosecuting for fraud can
choose between criminal or civil prosecution.
Civil Liabilities
In these cases, individuals or entities face substantial
monetary damages for each violation of program rules,
including repayment of up to three times the amount of
damages to the SoonerCare program and large fines.
 In either case, individuals or entities who have been convicted of
fraud may be excluded from participating in any federal health care
program for a specified period or indefinitely. In addition,
practitioners may have their licenses revoked by the state.
Liability and Penalties of Fraud and Abuse
The penalties for each type differ.
12
The Department of Health and Human
Services (HHS), which includes the Centers
for Medicare and Medicaid Services (CMS)
and OIG, has the authority to impose
remedial action or administrative
sanctions against individuals who
consistently fail to comply with Medicaid
law or are deemed abusive to the
SoonerCare program.
Liability and Penalties of Fraud and Abuse
Penalties for Fraud and Abuse
13
Penalties for Fraud and Abuse
 Provider education and warning
 Withholding the provider’s payments and recovery of
overpayments
 Termination of the SoonerCare contract
 Exclusion of the provider from the SoonerCare program and
posting of the provider’s name on a national Sanctioned
Provider list that is sponsored by the U.S. government
 Repayment of Federal funds
 Employee discipline, up to and including termination
 Loss of medical or other professional license
Liability and Penalties of Fraud and Abuse
The sanctions include the following:
14
Practice
What are the penalties that may be
imposed on individuals and providers who
are convicted of fraud?
A – Loss of their medical license
B – Substantial penalties, fines, and restitution
C – Civil penalties, plus triple damages
Liability and Penalties of Fraud and Abuse
Now try answering a few questions about
SoonerCare liability and penalties.
D – Imprisonment
E – All of the above
Click the appropriate answer.
15
Practice
all penalties that may be imposed
on the
individuals
What are
penaltiesand
thatproviders
may be who
imposed on are
individuals
and of
providers
convicted
fraud. who
are convicted of fraud?
A – Loss of their medical license
B – Substantial penalties, fines, and restitution
C – Civil penalties, plus triple damages
Liability and Penalties of Fraud and Abuse
Now try answering a few questions about
The correct
is E. These are
SoonerCare
liabilityanswer
and penalties.
D – Imprisonment
E – All of the above
15
A provider consistently bills for services in
excess of those needed by her patients.
What are the possible penalties that can be
imposed for her actions?
A – Withholding of her SoonerCare payments and the recovery of
SoonerCare’s overpayment
B – Civil penalties, including assessments per violation
C – Provider education and warning
Liability and Penalties of Fraud and Abuse
Practice
D – Exclusion of the provider from the SoonerCare program
E – All of the above
Click the appropriate answer.
16
The
correct answer
E. All ofin
A provider
consistently
bills forisservices
items
are possible
penalties
excessthese
of those
needed
by her patients.
What are the
possible
thatifcan be
that
could penalties
be imposed
imposed
for her actions?
SoonerCare
is billed for services in
excess of the patient’s needs.
A – Withholding of her SoonerCare payments and the recovery of
SoonerCare’s overpayment
B – Civil penalties, including assessments per violation
C – Provider education and warning
Liability and Penalties of Fraud and Abuse
Practice
D – Exclusion of the provider from the SoonerCare program
E – All of the above
16
Summary
 In the first part of the module you learned how you could be
personally responsible for fraud and abuse as a SoonerCare
provider.
 This module presented scenarios which helped you learn to
identify fraudulent and abusive activities.
 You also learned about the penalties and administrative
actions SoonerCare contractors impose on individuals who
commit fraud or abuse to the SoonerCare program.
Liability and Penalties of Fraud and Abuse
You have completed Module 5 – Liability and Penalties of
Medicaid Fraud and Abuse.
17
Identifying SoonerCare
False Claims, Fraud and
Abuse
Safeguarding Against Fraud and Abuse
12/01/2014 Version 1.01
Objectives
 Identify the safeguarding practices for protecting yourself
from SoonerCare fraud and abuse
 Identify the safeguarding practices for protecting yourself
from SoonerCare fraud and abuse initiated by other entities
 Identify the safeguarding practices for protecting your
patients
Safeguarding Against Fraud and Abuse
After completing this module, you will be able to:
2
 Ensure that services furnished
under the supervision of the
physician are furnished by
individuals who are
appropriately qualified or
licensed.
 Ensure that processes are in
place that guarantee
confidentiality
 Ensure that only authorized
individuals file claims on the
physician’s behalf
 Duplicate medical records,
bills, and claims forms should
be shredded or otherwise
destroyed.
Safeguarding Against Fraud and Abuse
Fraud and Abuse Safeguarding Checklist
3
Abusive actions and practices
could cost your business money
and result in potential fines,
penalties, or sanctions. In some
instances, these actions could
evolve into fraud if not remedied.
Fraudulent behavior could result
in severe monetary and legal
penalties, imprisonment,
or exclusion from the SoonerCare
program, depending on the level
of wrongdoing.
Safeguarding Against Fraud and Abuse
Introduction to Safeguarding
4
The Oklahoma Health Care Authority
recognizes that most SoonerCare providers
and contractors conduct their business in
accordance with established policies.
Unfortunately, accusations of fraud and
abuse have been made against physicians,
medical equipment suppliers, clinical labs,
members, and other health care providers.
You can protect yourself by understanding
how you are vulnerable and who is a
potential wrongdoer in the SoonerCare
program.
It is recommended that you implement as
many safeguard practices as possible to
prevent the occurrence of SoonerCare
fraud and abuse at your location.
Safeguarding Against Fraud and Abuse
Introduction to Safeguarding
5
Safeguarding Your Office
Safeguarding begins by making sure you have the appropriate
systems in place to follow SoonerCare guidelines.
Safeguarding Against Fraud and Abuse
Note: This section applies primarily to SoonerCare contractors,
but employees should also be aware of these safeguards.
6
When providing services to SoonerCare members, you are
responsible as a provider to abide by the three SoonerCare
Payment Premises:
1. Recognize what services are covered by SoonerCare
2. Recognize what services are medically necessary and
reasonable for the treatment of the patient’s condition
3. Document and properly report services according to
SoonerCare guidelines and procedures
Note
Correct documentation and proper reporting are common
areas where health care providers fall short in safeguards
for SoonerCare fraud and abuse
Safeguarding Against Fraud and Abuse
SoonerCare Payment Premises
7
Safeguarding Your Office






SoonerCare provider education
Billing and Procedures Manual
Provider Update Newsletter
“Dear Provider” letters
SoonerCare website
OHCA Call Center
Safeguarding Against Fraud and Abuse
The following resources are available to help you comply with
the SoonerCare Payment Premises:
8
Practice
A – Recognize which services are covered by SoonerCare
B – Recognize which services are medically necessary and reasonable for
the treatment of the patient’s condition
C – Document and properly report services according to SoonerCare
guidelines and procedures
D – All of the Above
Click the appropriate answer.
Safeguarding Against Fraud and Abuse
Which of the following are SoonerCare
Payment Premises?
9
Practice
The correct answer is D. All are
SoonerCare Payment Premises.
A – Recognize which services are covered by SoonerCare
B – Recognize which services are medically necessary and reasonable for
the treatment of the patient’s condition
C – Document and properly report services according to SoonerCare
guidelines and procedures
D – All of the Above
Safeguarding Against Fraud and Abuse
Which of the following are SoonerCare
Payment Premises?
9
As a provider, you are
responsible for all SoonerCare
payments that are generated
from all claims filed on your
behalf.
You can safeguard against billing
service fraud and abuse by:
 Carefully selecting your billing
service
 Regularly monitoring the
service and performance of
the billing service
Safeguarding Against Fraud and Abuse
Safeguarding Against Billing Service Fraud and Abuse
10
As a provider, you are
responsible for all SoonerCare
payments that are generated
from all claims filed on your
behalf.
You can safeguard against billing
service fraud and abuse by:
 Carefully selecting your
billing service
 Regularly monitoring the
service and performance of
the billing service
When selecting a billing service, verify
that the service meets the following
criteria:
• The service has reputable past
experience billing SoonerCare
claims. You can check references
from other providers and the
Better Business Bureau.
• The service’s electronic filing
system or program is compatible
with SoonerCare.
• The service performs extensive
claim edits that check all claims
prior to their submission to
SoonerCare for invalid diagnosis
and procedure codes, duplicate
claims, and unbundled
procedures.
Safeguarding Against Fraud and Abuse
Safeguarding Against Billing Service Fraud and Abuse
10
As a provider, you are
responsible for all SoonerCare
payments that are generated
from all claims filed on your
behalf.
You can safeguard against billing
service fraud and abuse by:
 Carefully selecting your billing
service
 Regularly monitoring the
service and performance of
the billing service
Regularly check the accuracy of
records and claims receipts for
claims submitted by your billing
service by confirming that:
•
•
•
Procedure, diagnosis, and
revenue codes were not
altered prior to submission
to SoonerCare.
Services were not
inappropriately unbundled.
Patients were charged the
appropriate amount.
Safeguarding Against Fraud and Abuse
Safeguarding Against Billing Service Fraud and Abuse
10
Practice
A – Checks claims prior to submission to SoonerCare for invalid diagnosis
and procedure codes, duplicate claims, and unbundled procedures
B – Has a reputable past experience billing SoonerCare claims
C – Files and remits claims electronically to SoonerCare in a compatible
format
D – All of the above
Click the appropriate answer.
Safeguarding Against Fraud and Abuse
Which of the following is the criteria for
selecting a billing service?
11
Practice
The correct answer is D. All are
criteria for selecting a billing
service.
A – Checks claims prior to submission to SoonerCare for invalid diagnosis
and procedure codes, duplicate claims, and unbundled procedures
B – Has a reputable past experience billing SoonerCare claims
C – Files and remits claims electronically to SoonerCare in a compatible
format
D – All of the above
Safeguarding Against Fraud and Abuse
Which of the following is the criteria for
selecting a billing service?
11
Physician Responsibilities
When someone uses a physician’s name,
license, or provider number (with or
without the physician’s knowledge) to
take advantage of patients and health
care programs, it becomes a concern to
the health care industry.
A physician who reassigns benefits to
another entity may be at risk of having
false claims filed with the physician’s
SoonerCare number, with or without the
physician’s knowledge.
Safeguarding Against Fraud and Abuse
Physicians are entrusted with and
expected to engage in activities that
promote the health and well-being of
their patients.
12
Physician Responsibilities
Safeguarding Against Fraud and Abuse
Each of the following scenarios are based on real situations.
13
Carla is an extremely organized office
manager for a pediatric practice.
However, the nurses and doctors she
works with are not organized. One
weekend Carla came in to the office to
get it cleaned up and organized. In this
process, she threw duplicate medical
records, bills, and claims forms in the
office dumpster.
Did Carla’s actions expose the practice
to fraud and abuse? How? What should
she have done differently? Could the
doctor be responsible if her actions
resulted in fraud or abuse?
Safeguarding Against Fraud and Abuse
Physician Responsibilities
13
Dr. Love is looking to expand the
office staff by adding a
physician’s assistant (PA) to the
practice. Dr. Love is introduced
to a PA, Kerri, who attends the
same church. Kerri seems very
professional and competent.
Because Dr. Love is so busy, he
hires Kerri and immediately puts
her to work seeing SoonerCare
members, without verifying
credentials.
Did Dr. Love do everything he
could to properly safeguard his
practice? How does he know
Kerri is a licensed P.A.? Is Dr.
Love responsible if Kerri
performs services and is not
licensed?
Safeguarding Against Fraud and Abuse
Physician Responsibilities
13
Physician Responsibilities
Before he hired Kerri, Dr.
Love should have checked
the following:
 Kerri’s license and
credentials
 The sanctioned provider
list to see if Kerri’s name
was on it
 The status of Kerri’s
current contract with
SoonerCare
Safeguarding Against Fraud and Abuse
As you have probably
guessed, Dr. Love and Carla
may have left their patients
and the practices susceptible
to fraud and abuse.
14
Carla should not have thrown the
documents in the dumpster. Someone
could retrieve the documents and sell
either the provider numbers or patient
information.
All documents containing confidential
information should be shredded or
otherwise destroyed.
The checklist on the following page can
be helpful when safeguarding your
office.
Safeguarding Against Fraud and Abuse
Physician Responsibilities
15
Fraud and Abuse Safeguarding Checklist
 Ensure that services furnished
under the supervision of the
physician are furnished by
individuals who are
appropriately qualified or
licensed.
 Ensure that processes are in
place that guarantee
confidentiality
 Ensure that only authorized
individuals file claims on the
physician’s behalf
 Duplicate medical records, bills,
and claims forms should be
shredded or otherwise
destroyed.
Safeguarding Against Fraud and Abuse
Fraud and Abuse Safeguarding
Checklist
16
Safeguarding Members
A common type of fraud can occur
when a member’s SoonerCare
number is lost or stolen and then
used to gain money or services from
the SoonerCare program.
Fraud can occur with or without the
member’s voluntary participation in
the scheme.
Safeguarding Against Fraud and Abuse
In addition to protecting medical
practices, it is also important to
safeguard members against fraud and
abuse.
17
One of the best ways to protect
patients is to maintain confidentiality
of their SoonerCare numbers and
medical records. Remember Carla? She
threw documents containing
confidential information in the
dumpster.
Shred or otherwise destroy reports
that include the patient names and
SoonerCare numbers so that the
confidentiality of the patient’s
SoonerCare information is protected.
This will ensure that information does
not get into the wrong hands.
Safeguarding Against Fraud and Abuse
Safeguarding Patients
18
Practice
A – A patient’s SoonerCare number is lost, stolen, or sold and then used
to gain illegal money or services from the SoonerCare program
B – A SoonerCare provider number is sold and used to bill SoonerCare
for unrendered services
C – Patients become professional patients. That is, they seek out medically
unnecessary health care services or items in exchange for a fee.
D – All the above
Click the appropriate answer.
Safeguarding Against Fraud and Abuse
Which of the following are examples of
fraud?
19
Practice
The correct answer is D. All are
examples of fraud.
A – A patient’s SoonerCare number is lost, stolen, or sold and then used
to gain illegal money or services from the SoonerCare program
B – A SoonerCare provider number is sold and used to bill SoonerCare
for unrendered services
C – Patients become professional patients. That is, they seek out medically
unnecessary health care services or items in exchange for a fee.
D – All the above
Safeguarding Against Fraud and Abuse
Which of the following are examples of
fraud?
19
As an integral part of our
commitment to prevent fraud,
waste, and abuse, SoonerCare has
adopted a Fraud Waste and Abuse
Compliance Program which
defines the procedures for
effective internal monitoring and
auditing of fraud, waste, abuse,
and risk assessment.
Safeguarding Against Fraud and Abuse
The Fraud, Waste, and Abuse Compliance Program
20
The Fraud, Waste, and Abuse Compliance Program
All phases of the SoonerCare program are monitored and audited.
 Automatic claims monitoring
through computer systems edits
 Unannounced audits or “spot
checks”
Safeguarding Against Fraud and Abuse
The Oklahoma Health Care Authority periodically monitors and
audits all types of claims using a variety of methods. Two of these
methods are:
21
The Fraud, Waste, and Abuse Compliance Program
 Random
 Complaint-based
 Topic area
Safeguarding Against Fraud and Abuse
Formal audits and monitoring may also be implemented.
These may be:
22
The Fraud, Waste, and Abuse Compliance Program
 Finance
 Quality Assurance
 Program Integrity
 Recovery Audit
Contractor
Safeguarding Against Fraud and Abuse
Audits and monitoring may also be conducted by various
departments within the agency including but not limited
to:
23
The Fraud, Waste, and Abuse Compliance Program
State Level Audit Group
Federal Level Audit Groups
Safeguarding Against Fraud and Abuse
The Oklahoma Health Care Authority, other state agencies, and
contractors that administer the SoonerCare Program can be
audited by several groups at the state and federal level.
24
The Fraud, Waste, and Abuse Compliance Program
State Level Audit Group
• Office of State Auditor and Inspector
Safeguarding Against Fraud and Abuse
The Oklahoma Health Care Authority, other state agencies, and
contractors that administer the SoonerCare Program can be
audited by several groups at the state and federal level.
24
The Fraud, Waste, and Abuse Compliance Program
Federal Level Audit Groups
• Office of Inspector General of the Department
of Health and Human Services
• Centers for Medicare and Medicaid Services
Safeguarding Against Fraud and Abuse
The Oklahoma Health Care Authority, other state agencies, and
contractors that administer the SoonerCare Program can be
audited by several groups at the state and federal level.
24
The Fraud, Waste, and Abuse Compliance Program
Once an audit identifies an abusive or fraudulent item, it may be dealt
with by:
 Education
 If the item in question resulted
in an overpayment of
SoonerCare funds, that money
must be repaid, including the
federal portion
Audit results may be appealed
Safeguarding Against Fraud and Abuse
Member issues are monitored and audited by the Office of Inspector
General of the Oklahoma Department of Human Services and OHCA
Program Integrity Member Audit Division
25
Practice
 Automatic claims monitoring through computer
systems edits
 Unannounced audits or “spot checks”
 Formal audits and monitoring
 Audits and monitoring conducted by various
departments within the agency
 Audits by various departments at the state and
federal levels
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Are all of the following methods used to
periodically monitor SoonerCare claims?
26
Click the appropriate answer.
Practice
Theclaims
correct
answerthrough
is Yes. computer
All of
 Automatic
monitoring
systemsthese
edits are methods used by the
 Unannounced audits or “spot checks”
Oklahoma Health Care Authority
 Formal audits and monitoring
periodically
monitor by
and
audit
 Auditsto
and
monitoring conducted
various
departments within
the agency
SoonerCare
claims.
 Audits by various departments at the state and
federal levels
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Are all of the following methods used to
periodically monitor SoonerCare claims?
26
General Self-check
Complete these self-check questions
that will raise your awareness about
safeguarding against fraud and abuse in
your office.
Safeguarding Against Fraud and Abuse
Are you ready to see if your practice is
safe from SoonerCare fraud and abuse?
27
Practice
Safeguarding Against Fraud and Abuse
When disposing of records, do you shred or
otherwise destroy reports that include patient
names and SoonerCare numbers?
A – NO
B – YES
28
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
When disposing of records, do you shred or
otherwise destroy reports that include patient
names and SoonerCare numbers?
28
Do you review the reports of sanctioned
individuals and entities to ensure that those
individuals or entities are not employed by or
contracted with you, or that you are not doing
business with them?
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Practice
29
Click the appropriate answer.
Do you review the reports of sanctioned
individuals and entities to ensure that those
individuals or entities are not employed by or
contracted with you, or that you are not doing
business with them?
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Practice
29
Practice
Safeguarding Against Fraud and Abuse
Is your provider number kept confidential and
shared only with those with an operational
need to know?
A – NO
B – YES
30
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Is your provider number kept confidential and
shared only with those with an operational
need to know?
30
Practice
Safeguarding Against Fraud and Abuse
Do you carefully review all documentation
before certifying the medical necessity of
services or supplies needed by your
SoonerCare patients?
A – NO
B – YES
31
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you carefully review all documentation
before certifying the medical necessity of
services or supplies needed by your
SoonerCare patients?
31
Practice
Safeguarding Against Fraud and Abuse
If you have authorized someone else to bill
SoonerCare for your services, do you have a
process in place to ensure that those billings
accurately reflect the service furnished?
A – NO
B – YES
32
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
If you have authorized someone else to bill
SoonerCare for your services, do you have a
process in place to ensure that those billings
accurately reflect the service furnished?
32
Practice
Safeguarding Against Fraud and Abuse
Have you done background checks on
companies and people you have contracted
with or hired in connection with your
SoonerCare business?
A – NO
B – YES
33
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Have you done background checks on
companies and people you have contracted
with or hired in connection with your
SoonerCare business?
33
Practice
Safeguarding Against Fraud and Abuse
Do you have a process in place to effectively
keep up with the changes in SoonerCare’s
guidelines and policies?
A – NO
B – YES
34
Click the appropriate answer.
Practice
The correct answer is Yes. The
OHCA has web alerts for updates,
provider letters and policy
changes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you have a process in place to effectively
keep up with the changes in SoonerCare’s
guidelines and policies?
34
Practice
Safeguarding Against Fraud and Abuse
Do you periodically check to ensure that
services you order for patients are the only
ones actually performed and billed to
SoonerCare?
A – NO
B – YES
35
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you periodically check to ensure that
services you order for patients are the only
ones actually performed and billed to
SoonerCare?
35
Practice
Safeguarding Against Fraud and Abuse
Do you notify SoonerCare, the state licensing
agency, or both, prior to making any changes
to the location of your business?
A – NO
B – YES
36
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you notify SoonerCare, the state licensing
agency, or both, prior to making any changes
to the location of your business?
36
Practice
Safeguarding Against Fraud and Abuse
Do you update your provider information on
OHCA’s provider portal?
A – NO
B – YES
37
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you update your provider information on
OHCA’s provider portal?
37
Practice
Safeguarding Against Fraud and Abuse
Do you fully document the services you bill to
SoonerCare, and do you have a process for
maintaining your records?
A – NO
B – YES
38
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you fully document the services you bill to
SoonerCare, and do you have a process for
maintaining your records?
38
Practice
Safeguarding Against Fraud and Abuse
Do you require appropriate approval before
billing staff makes changes to the billing
record?
A – NO
B – YES
39
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you require appropriate approval before
billing staff makes changes to the billing
record?
39
Practice
Safeguarding Against Fraud and Abuse
Do you have internal audits in place to detect
billing inaccuracies promptly?
A – NO
B – YES
40
Click the appropriate answer.
Practice
The correct answer is Yes.
A – NO
B – YES
Safeguarding Against Fraud and Abuse
Do you have internal audits in place to detect
billing inaccuracies promptly?
40
Practice
 If you follow all these guidelines, you should reduce your risk
of SoonerCare fraud and abuse.
Safeguarding Against Fraud and Abuse
You have completed the self-check questions for this module.
41
Summary
 This module covered the use of specific safeguarding practices
to protect yourself from SoonerCare fraud and abuse, as well
as from fraud and abuse initiated by other entities.
 Now you know the practices for safeguarding that will protect
you, your practice, and your patients
Safeguarding Against Fraud and Abuse
You have completed Module 6 – How to Safeguard Against Fraud
and Abuse.
42
Identifying SoonerCare
False Claims, Fraud and
Abuse
Reporting SoonerCare Fraud and Abuse
12/01/2014 Version 1.01
Objectives
 Identify the resources to use when reporting suspected
SoonerCare fraud and abuse.
 Identify the types of information needed to report suspected
fraud and abuse of the SoonerCare program.
 Identify the Whistleblower Protections provided by the False
Claims Act.
Reporting SoonerCare Fraud and Abuse
After completing this module, you will be able to:
2
If you should see or know about
any cases of SoonerCare fraud or
abuse, you should report these
cases to the appropriate
SoonerCare authorities.
Reporting SoonerCare Fraud and Abuse
Introduction to Reporting
3
Introduction to Reporting
Numbers to call include the following:
 OHCA’s Program Integrity
405-522-7421
 Attorney General’s Medical
Fraud Control Unit (MFCU)
OKC 405-521-3921
Tulsa 918-581-2885
 1-800-HHS-TIPS, OIG’s fraud
hotline number
Reporting SoonerCare Fraud and Abuse
Direct your reports to your SoonerCare contractor or to the
Office of the Inspector General (OIG) fraud hotline.
4
Reports to these numbers can be anonymous.
Helpful Information to Provide
When Reporting Fraud and Abuse
 Patient name
 Patient health insurance claim
number
 Date(s) of service
 Description of service or item
 Name of provider
 Address of provider
 Provider’s SoonerCare number
 An explanation or description of the
alleged fraudulent or abusive
activity
Reporting SoonerCare Fraud and Abuse
When reporting instances of fraud or
abuse, you may not have all the
information but it is important to
provide as much of what you know as
possible, including:
5
Whistleblower Protections
The False Claims Act basically says that
any employee who is discharged,
demoted, suspended, harassed, or
discriminated against for reporting
fraud and abuse will be reinstated with
full seniority, paid twice the amount of
back pay with interest on the back pay,
and compensated for any special
damages including litigation costs and
reasonable attorneys’ fees.
You can read the actual text regarding
whistleblower protection provided by
the False Claims Act on the next screen.
Reporting SoonerCare Fraud and Abuse
The False Claims Act contains a
whistleblower-protection provision for
persons reporting fraud and abuse.
6
Any employee who is discharged, demoted,
suspended, threatened, harassed, or in any other
manner discriminated against in the terms and
conditions of employment by his or her employer
because of lawful acts done by the employee on
behalf of the employee or others in furtherance of
an action under this section, including investigation
for, initiation of, testimony for, or assistance in an
action filed or to be filed under this section, shall be
entitled to all relief necessary to make the employee
whole.
Such relief shall include reinstatement with the same
seniority status such employee would have had but
for the discrimination, 2 times the amount of back
pay, interest on the back pay, and compensation for
any special damages sustained as a result of the
discrimination, including litigation costs and
reasonable attorneys' fees.
An employee may bring an action in the appropriate
district court of the United States for the relief
provided in this subsection.”
Reporting SoonerCare Fraud and Abuse
False Claims Act of 1986
7
The following three scenarios
each describe real events
involving reporting SoonerCare
fraud and abuse.
After reading each one, think
about what each person should
do.
Reporting SoonerCare Fraud and Abuse
Scenario
8
Bart is an employee of a state
agency that provides services
to SoonerCare members.
While reviewing some
paperwork, he notices that
his agency overstated the
services provided when
billing the Oklahoma Health
Care Authority. Bart isn’t
sure whether to report it or
not since the money is just
going from one state agency
to another.
Should Bart report this? Is it
fraud or abuse?
Reporting SoonerCare Fraud and Abuse
Scenario 1
9
Bart is an employee of a state
agency that provides services
to SoonerCare members.
While reviewing some
paperwork, he notices that
his agency overstated the
services provided when
billing the Oklahoma Health
Care Authority. Bart isn’t
sure whether to report it or
not since the money is just
going from one state agency
to another.
Should Bart report this? Is it
fraud or abuse?
Yes, Bart should report this. It
may be unintentional at this
point and qualify as abuse.
Reporting it will bring out the
facts.
Reporting SoonerCare Fraud and Abuse
Scenario 1
9
Jessica, an employee of the
Oklahoma Health Care
Authority, received a phone
call one day from someone
who did not want to identify
himself, but said that he
worked at a nursing home that
bills for services not rendered
to its SoonerCare members.
To whom should Jessica report
this violation?
Reporting SoonerCare Fraud and Abuse
Scenario 2
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Scenario 2
To whom should Jessica report
this violation?
Reporting SoonerCare Fraud and Abuse
Jessica, an employee of the
Oklahoma Health Care
Authority, received a phone
call one day from someone
who did not want to identify
himself, but said that he
worked at a nursing home that
bills for services not rendered
to its SoonerCare members.
Jessica should report it to
OHCA’s Program Integrity.
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Vanessa works in the billing
department for a large hospital.
She notices that newborn males
who are SoonerCare members are
transferred to another unit in the
hospital for their circumcisions
and the hospital consequently bills
twice for the same patient, calling
the move a transfer. The transfer
results in two diagnostic related
grouping (DRG) payments to the
hospital, which she believes
violates SoonerCare policy.
Vanessa would like to report this
information, but is afraid she will
lose her job. Should Vanessa
report this information? Could she
lose her job?
Reporting SoonerCare Fraud and Abuse
Scenario 3
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Vanessa works in the billing
department for a large hospital.
She notices that newborn males
who are SoonerCare members are
transferred to another unit in the
hospital for their circumcisions
and the hospital consequently bills
twice for the same patient, calling
the move a transfer. The transfer
results in two diagnostic related
grouping (DRG) payments to the
hospital, which she believes
violates SoonerCare policy.
Vanessa would like to report this
information, but is afraid she will
lose her job. Should Vanessa
report this information? Could she
lose her job?
Vanessa knows she is responsible for
reporting fraud and abuse so she
should report it. No, she will not lose
her job. The whistleblower
protections in the False Claims Act
will protect her job.
Reporting SoonerCare Fraud and Abuse
Scenario 3
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Practice
A – OHCA’s Program Integrity or OIG’s Fraud Hotline, 1-800-HHS-TIPS
B – Federal Safety Administration
C – Oklahoma Department of Human Services hotline
D – All of the above
Click the appropriate answer.
Reporting SoonerCare Fraud and Abuse
Which of these resources can you use to
report suspected cases of SoonerCare fraud
and abuse?
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Practice
suspected cases of SoonerCare fraud
and abuse to the OHCA’s Program
Integrity or OIG’s Fraud Hotline.
A – OHCA’s Program Integrity or OIG’s Fraud Hotline, 1-800-HHS-TIPS
B – Federal Safety Administration
C – Oklahoma Department of Human Services hotline
D – All of the above
Reporting SoonerCare Fraud and Abuse
Which of these resources can you use to
report suspected cases of SoonerCare fraud
and abuse?
The correct answer is A. You may report
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Should try to provide all of these the types of
information when reporting suspected fraud or
abuse.
 Patient name
 Patient SoonerCare number
 Date(s) of service(s)
 Description of service or item
 Name of provider
 Provider’s SoonerCare number
 Address of provider
A – NO
B – YES
Reporting SoonerCare Fraud and Abuse
Practice
13
Click the appropriate answer.
Should try to provide all of these the types of
information when reporting suspected fraud or
abuse.
correct answer is Yes. When
 PatientThe
name
reportingnumber
suspected fraud or
 Patient SoonerCare
abuse,
you should provide as
 Date(s) of
service(s)
much
information
 Description
of service
or item as possible.
 Name of provider
 Provider’s SoonerCare number
 Address of provider
A – NO
B – YES
Reporting SoonerCare Fraud and Abuse
Practice
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You have completed Module 07 – Reporting SoonerCare Fraud
and Abuse.
 In this module, you learned about the available resources to
use when reporting suspected SoonerCare fraud and abuse.
 In addition, you now know the types of information needed
when you are reporting fraud and abuse, as well as the
 Whistleblower Protections provided by the False Claims Act.
The bottom line is if you know fraud or abuse is going on, you
should have no fear of retribution. It’s everyone’s responsibility
to report it and it’s the right thing to do.
Reporting SoonerCare Fraud and Abuse
Summary
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Identifying SoonerCare
False Claims, Fraud and
Abuse
Post-Assessment
12/01/2014 Version 1.01
Introduction
Post-Assessment
This Post-Assessment consists of 15 questions.
 Take just a few minutes to complete this Post-Assessment.
 The assessment consists of 15 questions.
 The purpose of the Post-Assessment is to see what you’ve
learned concerning SoonerCare fraud and abuse.
2
Practice
What is the best definition of SoonerCare
fraud?
B – Knowingly executing a scheme against the SoonerCare program
C – Willfully executing a scheme against the SoonerCare program
D – All of the above
Click the appropriate answer.
Post-Assessment
A – Attempting a scheme against the SoonerCare program
3
Practice
What is the best definition of SoonerCare
fraud?
The correct answer is D. All are
examples of SoonerCare fraud.
B – Knowingly executing a scheme against the SoonerCare program
C – Willfully executing a scheme against the SoonerCare program
D – All of the above
Post-Assessment
A – Attempting a scheme against the SoonerCare program
3
Practice
What is the best definition of SoonerCare
abuse?
B – Intentionally violating SoonerCare guidelines
C – Unknowingly violating SoonerCare guidelines
D – None of the above
Click the appropriate answer.
Post-Assessment
A – Knowingly defrauding the SoonerCare program
4
Practice
What is the best definition of SoonerCare
abuse?
The correct answer is C.
SoonerCare abuse is unknowingly
violating SoonerCare guidelines.
B – Intentionally violating SoonerCare guidelines
C – Unknowingly violating SoonerCare guidelines
D – None of the above
Post-Assessment
A – Knowingly defrauding the SoonerCare program
4
Practice
Post-Assessment
If a provider charges a patient for a service
that is not covered by SoonerCare, has
fraud or abuse occurred?
A – NO
B – YES
5
Click the appropriate answer.
Practice
The correct answer is NO.
Charging a patient for a service
that is not covered by SoonerCare
does not constitute fraud or
abuse.
A – NO
B – YES
Post-Assessment
If a provider charges a patient for a service
that is not covered by SoonerCare, has
fraud or abuse occurred?
5
Practice
Post-Assessment
If someone completes a certificate of
medical necessity without a physician’s
involvement in the care of the patient, has
SoonerCare fraud or abuse occurred?
A – NO
B – YES
6
Click the appropriate answer.
Practice
The correct answer is Yes. A
physician’s involvement is
required for a certificate of
medical necessity form.
A – NO
B – YES
Post-Assessment
If someone completes a certificate of
medical necessity without a physician’s
involvement in the care of the patient, has
SoonerCare fraud or abuse occurred?
6
Practice
Post-Assessment
A provider collects more than the
established co-payment amounts from a
patient for medical treatment. Has
SoonerCare fraud or abuse occurred?
A – NO
B – YES
7
Click the appropriate answer.
Practice
The correct answer is Yes.
SoonerCare providers are not
allowed to collect more than the
established co-payment.
A – NO
B – YES
Post-Assessment
A provider collects more than the
established co-payment amounts from a
patient for medical treatment. Has
SoonerCare fraud or abuse occurred?
7
Practice
B - Abuse
Post-Assessment
A SoonerCare provider requires a deposit
from a SoonerCare member as a condition
for continued care. Is this violation fraud,
abuse, or neither?
C - Neither
8
A - Fraud
Click the appropriate answer.
Practice
A SoonerCare provider requires a deposit
from a SoonerCare member as a condition
for continued care. Is this violation fraud,
abuse,
neither?answer is A. A provider
Theorcorrect
B - Abuse
Post-Assessment
that requires a deposit from a
member as a condition for continued
care has committed fraud.
C - Neither
8
A - Fraud
Practice
B - Abuse
Post-Assessment
A provider intentionally upcodes services to
a higher level in order to receive a larger
reimbursement from SoonerCare. Is this
violation fraud, abuse, or neither?
C - Neither
9
A - Fraud
Click the appropriate answer.
Practice
A provider intentionally upcodes services to
a higher level in order to receive a larger
reimbursement from SoonerCare. Is this
violation
abuse,
or neither?
The fraud,
correct
answer
is A. Upcoding
B - Abuse
Post-Assessment
services to a higher level to receive a
larger SoonerCare reimbursement is
an example of fraud.
C - Neither
9
A - Fraud
Practice
Post-Assessment
Are providers financially liable if their billing
services commit fraud without the
provider’s knowledge?
A – NO
B – YES
10
Click the appropriate answer.
Practice
The correct answer is Yes.
Providers are financially liable if
their billing services commit
fraud, even without the provider’s
knowledge.
A – NO
B – YES
Post-Assessment
Are providers financially liable if their billing
services commit fraud without the
provider’s knowledge?
10
Practice
Post-Assessment
Are providers financially liable for all claims
submitted on their behalf that contain their
SoonerCare identification number?
A – NO
B – YES
11
Click the appropriate answer.
Practice
The correct answer is Yes. Providers
are financially liable for all claims
submitted on their behalf that contain
their SoonerCare identification
number.
A – NO
B – YES
Post-Assessment
Are providers financially liable for all claims
submitted on their behalf that contain their
SoonerCare identification number?
11
Practice
Which of the following penalties can occur
if you are liable for SoonerCare abuse?
B – Your assignment privileges can be revoked.
C – You can be imprisoned
D – All of the above
Click the appropriate answer.
Post-Assessment
A – You can be obligated to participate in provider education initiatives.
12
Practice
Which of the following penalties can occur
if you are liable for SoonerCare abuse?
The correct answer is D. All are
penalties that can occur if you are
suspected of SoonerCare abuse.
B – Your assignment privileges can be revoked.
C – You can be imprisoned
D – All of the above
Post-Assessment
A – You can be obligated to participate in provider education initiatives.
12
Practice
A – Ensure that your SoonerCare provider number is noted on all
documents for all staff to see so that they can verify your
SoonerCare provider status.
B – Make sure SoonerCare guidelines and updates are regularly
circulated among appropriate claim and billing staff and
implemented in your systems.
C – Make sure that a Waiver of Liability is being provided to patients for
all services performed.
D – Confirm that all employees or providers hired or contracted with are
not on the Sanctioned Provider List.
Click the appropriate answer.
Post-Assessment
When implementing safeguards to prevent
SoonerCare fraud and abuse, you should
keep which of the following in mind?
13
Practice
A – Ensure that your SoonerCare provider number is noted on all
documents for all staff to see so that they can verify your
SoonerCare provider status.
B – Make sure SoonerCare guidelines and updates are regularly
circulated among appropriate claim and billing staff and
implemented in your systems.
C – Make sure that a Waiver of Liability is being provided to patients for
all services performed.
D – Assume that all employees or providers hired or contracted with are
not on the Sanctioned Provider List.
Post-Assessment
The correct answer is B. When implementing safeguards to
preventimplementing
fraud and abuse
you shouldtomake
sure SoonerCare
When
safeguards
prevent
guidelines and updates are regularly circulated among
SoonerCare fraud and abuse, you should
appropriate billing staff and implemented in your systems
keep
of all
theemployees
followingor
inproviders
mind? are not on the
andwhich
confirm
Sanctioned Providers List.
13
Practice
A – Charges for their service on the basis of the number of claims they
file rather than at a single monthly rate
B – Guarantees the confidentiality of your SoonerCare provider number
and other personal information
C – Conducts routine audits of patient charge amounts for services
rendered by the provider
D – All of the above
Click the appropriate answer.
Post-Assessment
When selecting a billing service to use, you
should choose a service that:
14
Practice
Theselecting
correct aanswer
is D. You
When
billing service
to should
use, youalways
select
a billing
service
that:
should
choose
a service
that:
A – Charges for their service on the basis of the number of claims they
file rather than at a single monthly rate
B – Guarantees the confidentiality of your SoonerCare provider number
and other personal information
C – Conducts routine audits of patient charge amounts for services
rendered by the provider
D – All of the above
Post-Assessment
• Charges on the basis of the number of claims
filed rather than a monthly rate
• Guarantees confidentiality
• Conducts routine audits of patient charge
amounts for services rendered by the provider
14
Practice
To safeguard from fraud and abuse,
providers should choose a laboratory that:
B – Monitors the test request forms to ensure that there is a diagnosis
code defining the reason why each test was ordered
Post-Assessment
A – Does not change diagnosis codes on the original test request form
C – All of the above
D – None of the above
Click the appropriate answer.
15
Practice
The correct
answer
is C.abuse,
When selecting a
To safeguard
from
fraud and
lab, you
should
choose
one thatthat:
does not
providers
should
choose
a laboratory
change diagnosis codes and monitors test
request forms to ensure that there is a
diagnosis code defining the reason each
test was ordered.
B – Monitors the test request forms to ensure that there is a diagnosis
code defining the reason why each test was ordered
Post-Assessment
A – Does not change diagnosis codes on the original test request form
C – All of the above
D – None of the above
15
Practice
What is the term used in the False Claims
Act that refers to a person reporting fraud
and abuse?
Post-Assessment
A – Singer
B – Tattletale
C – Informant
D – Whistleblower
Click the appropriate answer.
16
Practice
What is the term used in the False Claims
Act that refers to a person reporting fraud
and abuse?
The correct answer is D. The term that is
used in the False Claims Act that refers to
a person reporting fraud and abuse is
whistleblower
B – Tattletale
C – Informant
D – Whistleblower
Post-Assessment
A – Singer
16
Practice
The False Claims Act contains a
whistleblower-protection provision for
persons reporting fraud and abuse. What
does this mean?
A – Persons reporting fraud or abuse may be subject to the same
penalties as the person committing the fraud or abuse.
C – Persons reporting fraud and abuse who are discharged, demoted,
suspended, harassed, or discriminated against have protection from
such actions.
D – Persons reporting fraud and abuse will be guaranteed another
position if they are discharged from their current position.
Click the appropriate answer.
Post-Assessment
B – Persons reporting fraud or abuse can be discharged or demoted.
17
Practice
The False Claims Act contains a
whistleblower-protection provision for
persons reporting fraud and abuse. What
The correct answer is C. Persons who are
does this mean?
C – Persons reporting fraud and abuse who are discharged, demoted,
suspended, harassed, or discriminated against have protection
from such actions.
D – Persons reporting fraud and abuse will be guaranteed another
position if they are discharged from their current position.
Post-Assessment
discharged, demoted, suspended,
A – Personsor
reporting
fraud or abuse
may befor
subject to the same
harassed,
discriminated
against
penalties
as theor
person
committing
the fraud or abuse.
reporting
fraud
abuse
have protection
from
such actions.
B – Persons
reporting fraud or abuse can be discharged or demoted.
17
Congratulations!
You have completed the Post-Assessment and the Identifying
SoonerCare False Claims, Fraud and Abuse online course.
Post-Assessment
Close this window and return to www.ok.train.org to view
and/or print your certificate of completion.
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