Could you become the target of investigation for healthcare fraud or abuse?

It’s possible — not because you are deliberately breaking the law, but because you may be unintentionally engaging in illegal conduct through ignorance or misunderstanding of laws, rules or regulations that govern healthcare.

A simple definition of healthcare fraud is an intentional deception or misrepresentation that could result in an unauthorized payment. Healthcare abuse is conduct that is inconsistent with accepted industry standards that could result in unnecessary costs to a healthcare program.

Healthcare fraud and abuse are major problems in the United States and their prevalence has affected the affordability and availability of healthcare. Insurers, regulators and law enforcers have focused significant attention on the problem and have promulgated new laws and rules that make fraud and abuse easier to prosecute. Enforcement interest is at an all time high today.

When enforcers identify activities that run contrary to the law, they are charged with the obligation to investigate. They have no way of knowing if the transgression is intentional. And, in fact, ignorance of the law is no excuse!

The way to keep enforcers at bay: Stay informed and operate within the letter and spirit of the law.

Are you complying with the law? Take the following True-False mini-quiz to see where you stand on some critical issues for today’s healthcare provider. The answers are given at the end of the quiz.

1 True or false? Saying it was a mistake caused by not know-ing the laws, rules and regulations governing healthcare is a sound defense to allegations of fraud or abuse.

2 True or false? Per CPT (Current Procedural Terminology) a non-licensed person may render therapeutic procedures (CPT codes 97110 – 97546).

3 True or false? Per CPT, the time for time-based services or procedures starts when the provider (that is, a licensed healthcare provider) is in direct one-on-one contact with the patient to set-up, administer and clean up the service or procedure.

4 True or false? To document time properly in the patient’s clinical record on time-based services or procedures rendered, the start and end time of the service or procedure should be reported.

5 True or false? Per CPT, a healthcare provider can report a CPT code that closely resembles the service rendered if the third-party payor does not reimburse the actual service or procedure rendered. For example, the provider can use CPT 97032 (attended electrical muscle stimulation) if the payor does not reimburse for CPT 97014 (unattended electrical muscle stimulation).

The answers are …
1. False. Ignorance of the laws, rules and regulations governing healthcare is not a valid defense in today’s enforce-ment climate. A lack of knowledge could be interpreted as a reckless disregard, which is defined as having no regard to whether the information presented on a claims was true or false, and with deliberate ignorance, choosing to ignore the truth or falsity of the information on the claim.

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