2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Legal15. Fraud, Waste, and Abuse15. Fraud, Waste, and AbuseAs a health plan, Presbyterian is required tocooperate with regulatory and law enforcementagencies in reporting any activity that appears to besuspicious in nature. According to the law, anyinformation that we have concerning such mattersmust be turned over to the appropriategovernmental agencies.By identifying areas of concern relative to fraud,waste, and abuse, and working with physicians andother health care providers to make improvements,Presbyterian is able to dedicate more resources toour goal of improving the health of patients,members, and communities.This chapter of the provider manual is intended toeducate providers on fraud, waste, and abuse andto comply with the Centers for Medicare andMedicaid Services (CMS) mandatory requirementthat providers receive the training.Regulatory DefinitionsFraud is defined as intentional deception ormisrepresentation made by an entity or person,including but not limited to a subcontractor, vendor,provider, member, or other customer with theknowledge that the deception could result in someunauthorized benefit to a person or an entity. Fraudincludes any attempt to obtain, by means of false orfraudulent pretenses, representations, or promises,any of the money or property owned by or underthe custody or control of, any health care benefitprogram. It includes any act that constitutes fraudunder applicable state and federal law. Forexample, fraud may exist when a provider bills forservices not rendered, and the service cannot besubstantiated by documentation.Waste is defined as an act involving payment orthe attempt to obtain payment for items or serviceswhere there was no intent to deceive ormisrepresent, but where the outcome of poor orinefficient methods resulted in unnecessary costs tothe plan.Abuse is defined as incidents or practices that areinconsistent with accepted and sound business,fiscal, or medical administrative practices. Abusemay, directly or indirectly, result in unnecessarycosts to the health plan, improper payment, orpayment for services that fail to meet professionalstandards of care or are medically unnecessary.Abuse consists of payment for items or serviceswhen there is no legal entitlement and the recipienthas knowingly misrepresented the facts to receivethe benefit or payment. Abuse often takes the formof claims for services not medically necessary ornot medically necessary to the extent provided.Abuse also includes practices by subcontractors,providers, members, or customers that result inunnecessary costs to the health plan. For example,abuse may exist when the provider fails toappropriately bill new and established patient officecodes. The provider bills a “new” patient code bothon the initial visit and subsequent visits.15-12014 Practitioner and Provider Manual - Ver. 3