Tag Archives: fraud-waste-abuse

Program Integrity Federalism

From time to time someone among our newer Chapter members working in the insurance industry reports confronting instances of Medicaid and Medicare fraud for the first time. I thought it might be helpful to present some of the more common health care fraud scenarios that beginning fraud examiners are likely to confront in actual practice in the governmental health care space.

Abuses of the Medicaid and Medicare programs exist in myriad shapes and sizes and continue to evolve constantly. While Medicaid and Medicare fraud, waste and abuse appear to be the most egregious program issues, incidental and accidental waste also threaten program integrity, including outright criminal exploitation of governmental health care payments. Altogether, the overpayment of Medicaid and Medicare dollars represents the largest portion of misused government money, accounting for 59 percent of the $102.2 billion the government improperly distributed among all its agencies in 2017 (ACFE). Issues involving these exorbitantly expensive improper payments can be attributed, in part, to the complexities of the programs themselves and to ever-changing policies among the various states.

It’s important for new anti-fraud practitioners to be aware that while Medicaid and Medicare are considered universal programs, each state is able to operate its own version of the programs autonomously and independent of any collective standard. This autonomy creates wide-ranging policy inconsistencies due to the differences among states, and, in many ways, embodies the ideals of American federalism. How states administer programs like Medicaid and Medicare is largely influenced by the bureaucratic style employed by the state legislature. These variations and inconsistencies can facilitate inaccuracies and misunderstandings in every aspect of both programs, from recipient eligibility, billing protocols, coding standards and licensure requirements. Doctors offering Medicaid or Medicare services are not easily able to transfer their practices from one state to another without first exploring expectations and requirements of the new state. These hard state boundaries create the potential for provider, beneficiary and administrative confusion, which ultimately equates to billions of program dollars misappropriated each year.

Beyond the innocent misappropriation of program dollars are the much more serious problems with the Medicaid and Medicare programs manifesting in the form of illicit and purposeful instances of fraud, waste and abuse perpetrated by recipients and providers. Medicaid and Medicare identity theft (instances of which have been recently investigated by one of our Chapter members) much like general identify theft, has continually resurfaced as a bane since the programs’ inception. It is estimated that three percent of $50 billion of the nation’s annual identity theft losses is associated with some type of medical identity theft. Because of their likelihood of being enrolled in government-facilitated insurance programs like Medicare or Medicaid, individuals aged 50 or older are most likely to fall victim to this type of identity theft. Fraudsters steal these identities to access services, such as prescriptions for drugs with high black-market value i.e. OxyContin, Fentanyl and Morphine, intended for legally enrolled, authorized recipients. Once the prescription is obtained, the thieves sell the drugs for cash or abuse them themselves.

A similar identity theft scheme involves the sale of durable medical equipment prescribed to recipients. By stealing a beneficiary’s Medicaid or Medicare number, the perpetrator can place orders for equipment i.e. slings or braces, all paid for through program dollars, and re-sell the goods online or via newspaper classifieds for cash.

Physicians participating in the Medicaid and Medicare programs also have access to a wide range of possible fraud, waste and abuse schemes. Double billing is a common provider fraud scheme that involves the submission of duplicate claims to Medicaid or Medicare in an attempt to receive double the amount of payment for services that were only provided once. Those physicians wise to the high detectability of billing duplicate claims to either program via simple data analysis will also often send one bill to a private insurance company and a duplicate bill to Medicaid or Medicare so that the duplication does not appear within one data set. Other fraud schemes include up-coding bills to Medicare or Medicaid to represent more complex, lengthy or in-depth procedures when a simpler or lower-level service was actually provided or performed.

Usually, complex procedures are paid at a higher dollar amount than their simpler counterparts, which leads providers to be paid more money than what they actually earned during the office visit or procedure. This fraud scheme takes advantage of small but specific variations in the current procedural terminology (CPT) coding system standardized for both Medicaid and Medicare coverage. Similar to up-coding is the fraudulent unbundling of CPT codes billed as individual entities that per regulation should be grouped together and billed under one umbrella code. Usually, the umbrella code pays a discounted rate for all the services combined. Each individual code gets paid an amount that, when totaled together, equals more than what the umbrella code pays.

Dishonest Medicaid and Medicare providers also bill for services that are not medically necessary. In this scheme, providers perform and bill for services and/or testing beyond what patient need requires. Under this scheme, hospital stays are lengthened, additional diagnostic testing is ordered, entitled hospice enrollment is invoked too early, and equipment and tools are wasted for beneficiaries who really require less care and fewer services. This fraud scheme not only wastes program dollars but also strains other areas of the general healthcare system by inducing and allowing individuals to linger, thus monopolizing unnecessary services and care that could be better applied to other more worthy beneficiaries. But please be aware, while Federal regulation does not contain a definition of medical necessity, states are granted authority to develop and apply medical necessity criteria as they see fit. Providing and billing for services beyond the required needs of the beneficiary may be intentional and/or fraudulent, but because of differing state criteria, instances where unnecessary services are provided and billed may also be simply accidental or well-intentioned.

Anti-fraud professionals of all kinds should also bear in mind that, while Medical identity theft, double billing, up-coding, unbundling and billing for services not medically necessary represent only a portion of the known problems and schemes that weaken the Medicaid and Medicare programs, there are many other types of program fraud, waste and abuse occurring on a daily basis that have yet to be discovered; in this area of practice, expect the unexpected. According to the ACFE, in the past 27 years the Federal government has recovered approximately $24 billion in settlements or judgments against individuals and organizations who committed both accidental and purposeful healthcare fraud, waste and abuse.

On a state level, another $15 billion has been recouped from criminal fines and civil settlements resulting from the prosecution of healthcare fraudsters. While the $39 billion in recovered overpayments from the last 27 years is only enough to cover a small percentage of one year’s total program costs, the amount of overpayment dollars recovered each year by the Federal and state governments is growing exponentially. On average only about $1.4 billion in overpayments was recovered during that time period. However, in 2016 alone, $3.1 billion in healthcare fraud judgments and settlements was recovered by the Federal government. As Medicaid and Medicare fraud, waste and abuse schemes and problems become more prevalent their financial toll increases. Federal and state governments are also detecting and reclaiming money back on a larger scale. This increase can be attributed to developments in policy created to prevent and identify fraud, increased investigative and program integrity funding, and technological improvements in fraud detection programs, databases and software; Certified Fraud Examiners (CFE’s) will increasingly find themselves at the forefront of the effort to strengthen health care program integrity at the Federal level and within each state.

Zack is Back on Internal Investigations!

Our Chapter is looking forward with anticipation to our next two-day training event (May 17th and 18th) when we will again have Gerry Zack, one of the ACFE’s best speakers, presenting on the topic ‘Conducting Internal Investigations’.  Gerry was last with us several years ago, when he taught ‘Introduction to Fraud Examination’ to an overflow crowd; judging from the number of early registrations, it looks like this year’s event will be an attendance repeat!

One of the training event segments Gerry presented in detail last time dealt with related party transactions internal to the organization and some of the unique challenges they can pose for fraud examiners.  Such ethical lapses take the form of schemes where individuals who approve one or more transactions for their organizations also benefit personally from them.  Per the ACFE, the business processes most affected by such scenarios are the loan function, the sales function and corporate purchases.

Regarding loan schemes, the key risks fraud examiners should look for are:

— The provision of loans to senior management, other employees, or board members at below-market interest rates or under terms not available in the marketplace;
— Failure to disclose the related party nature of the loan;
— The client organization providing guarantees for private loans made by employees or board members.

In these scenarios, the favorable terms benefit the employee at the expense of the employing organization.  To identify undisclosed loans to senior management, board members, and employees, the CFE could search for related-party loans using data analysis to compare the names on all notes receivables and accounts receivables with employee names from payroll records and board member names from board minutes. If a match occurs, the CFE should assess whether the related-party transaction was appropriately authorized and disclosed in the accounting records and financial statements.  Examiners can also search for undisclosed related-party loans by examining the interest rate, due dates, and collateral terms for notes receivables.  Notes receivable containing zero or unusually low interest rates, or requiring no due dates or insufficient collateral, may indicate related-party transactions.  The CFE can also examine advances made to customers or others who owe money to her client organization. Organizations generally do not advance money to others who owe them money unless a related-party relationship exists.

Gerry’s presentation for related party sales pin-pointed red flags like employees:

— Selling products or services significantly below market price or providing beneficial sales terms that ordinarily would not be granted to arms-length customers.
— Inflating sales for bonuses or stock options using related parties to perpetrate the scheme. Either a sale really has not taken place because the goods were not shipped or there was an obligation to repurchase the goods sold so the sale was incomplete.
— Approving excessive sales allowances or returns as well as accounts receivable adjustments or write-offs for related parties.

To cover up the related-party transaction, employees may deny reviewers access to customers to impede them from acquiring evidence concerning the related-party relationship.  Where the CFE suspects related party sales, s/he should perform analytical procedures to compare price variations among customers to identify those who pay significantly below the average sales price. Examiners can also attempt to identify any customer who pays prices that differ from the approved price sheet. Customer contracts can be directly analyzed for unusual rights of return, obligations to repurchase goods sold, and unusual extended repayment terms. Analytical procedures to identify customers with excessive returns, sales allowances, account receivable adjustments, or write-off’s may also be performed. Any variances in these areas might indicate undisclosed related-party transactions. Gerry also point out that data analysis can be used to efficiently compare employee addresses, telephone numbers, tax identification numbers, and birthdays with customer addresses, telephone numbers, tax identification numbers, and company organization dates. When creating a shell company, many individuals use their own contact information for convenience and their own birth date as the organization date because it is easy to remember. Any matches could indicate a related-party association and should be investigated minutely.

For third party purchases schemes, some of the key red flags are:

— the company paying prices significantly above market for goods or services;
— the company receiving significantly below average quality goods or services that are purchased at market prices for high quality goods or services;
— the company never actually receiving the purchased goods or services.

CFE’s should consider comparing cost variations among vendors to identify those whose costs significantly exceed the average cost. For identified variances, examiners should discover why the cost variations occurred to assess whether a related-party relationship exists. Like the examination steps for customers, it’s important to compare the employee’s address, telephone number, tax identification number, and birth date to vendors’ information to see if a relationship exists. CFE’s can also assess the use of sales intermediaries for products they can purchase directly from the manufacturer at lower costs.

For the comprehensive review of all this information, Gerry stressed that the level and quality of client company documentation is critical.  In reviewing their client organization’s documentation, the CFE may find that the organization does not have in place any policies or procedures prohibiting related-party relationships or transactions without prior approval. The organization also may not provide training to employees around related-party relationships and transactions, or require employees even to certify whether they are involved in any conflicts of interest with the organization. CFE’s should recommend, as a component of the fraud prevention program, that their client organization maintain written policies and procedures defining the process for obtaining approval for related-party relationships and transactions.

Key risks exist if:

— Written related-party policy and procedures are nonexistent or insufficient;
— Employees are not required to certify regularly whether they have a conflict of interest;
— Related-party transactions are not approved in accordance with established organizational policies and procedures;
— Related-party transactions are approved with exceptions to organizational policies and procedures.

The CFE should review approved related-party policies and procedures documentation. If related-party policies or procedures don’t exist or if they don’t sufficiently mitigate the risk of unauthorized or inappropriate related-party relationships or transactions, the examiner should consult with senior management and the board, if necessary, to offer guidance on a pro-active basis toward the development of such policies and procedures as a key fraud prevention measure.  The CFE should also review conflict of interest statements. If an employee documents a conflict of interest in his or her statement, the examiner should assess whether the conflict of interest was appropriately authorized and whether the process recognizes and discloses conflicts of interest.

Third party transactions are but a single topic of many to be covered by Gerry in our May event.  If you are called upon by your employer to investigate instances of fraud, waste and abuse both within your parent company and within related business affiliates, this is a seminar for you.  A well run internal investigation can enhance an enterprise’s well-being and can help detect the source of lost funds, identify responsible parties and recover losses. It can also provide a defense to legal charges by terminated or disgruntled employees. But perhaps most importantly, an internal investigation will signal to other employees that the company will not tolerate fraud. This seminar will prepare you for every step of an internal investigation into potential fraud, from receiving the initial allegation to testifying as a witness. Learn to lead an internal investigation with accuracy and confidence by gaining knowledge about key topics, such as relevant legal aspects of internal investigations, using computers in an investigation, collecting and analyzing internal information, interviewing witnesses and writing reports.

There are only 70 training slots available and our seminars fill up fast!  If you are interested in this vital investigative topic, you can find the seminar agenda, venue information, speaker bio and registration information at http://rvacfes.com/events/conducting-internal-investigations/.