Fighting Healthcare Fraud and Abuse: The Stakes and Consequences

Why Should You Attend:

Health care fraud is an intentional misrepresentation, deception, or intentional act of deceit for the purpose of receiving greater reimbursement. Health care abuse is reckless disregard or conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in greater reimbursement.

This webinar will help attendees to identify fraud early, root it out quickly, and protect patients from the harmful consequences of fraud. It will provide a powerful deterrent to would-be perpetrators looking to prey on patients and steal money from taxpayers.

Areas Covered in the Webinar:

• Understand Fraud, Waste, and Abuse (FWA) training requirements
• What laws regulate Fraud, Waste, and Abuse
• Describe steps taken to prevent and combat FWA
• Refer suspected FWA to your special investigations unit
• Understand the federal Whistle Blowers Act
• Understand STARK law
• Fraud and abuse case studies
• Increased law enforcement coordination in 2016
• Medicare Part D enforcement
• NPI compromise could lead to fraud charges
• Whistleblower laws

Who Will Benefit:

This webinar will provide valuable assistance to all personnel in medical offices, practice groups, hospitals, academic medical centers, insurers, business associates (shredding, data storage, systems vendors, billing services, etc.). The titles are:

• Compliance Director
• CEO
• CFO
• Insurance Claim Auditors
• Insurance Fraud Examiners
• Privacy Officer
• Security Officer
• Information Systems Manager
• HIPAA Officer
• Chief Information Officer
• Health Information Manager
• Healthcare Counsel/Lawyer
• Office Manager
• Contracts Manager
• Medical Coders
• Medical Billers

Instructor Profile:

Michael A. Reynolds, CPC, CCP-P, CPMB, CBCS, OS, OS has over 26 years’ experience in the Health Care field with expertise in areas such as Health Care Management, Medical Billing and Collections, Medical Coding, Medical Reimbursement, Managed Care Claims Processing and Appeals, Customer Service Rep., Premium Service Rep., Health Care Compliance management, Medical Coding and Billing Instructor. Michael has served as the 2005, 2008 and 2011 President of the San Diego Chapter of the American Academy of Professional Coders, and is a current Board Member for National Health career Association. Michael is a current Member of the American Academy of Professional Coders, member of the Professional Medical Billers Association and the board of medical specialty coding. Michael currently teaches both medical billing and coding and electronic health records at San Diego state university and is part owner of Pitt & Reynolds Medical Coding and Consulting.

Topic Background:

Health care fraud and abuse is a national problem that affects each of us either directly or indirectly and affects both health care quality and safety. The financial losses to health care fraud nationwide are estimated to cost tens of billions of dollars a year, according to the National Health Care Anti-Fraud Association. These losses lead to increased health care costs and potential increased costs for coverage. Fraud and abuse also can result in serious harm to people who are subjected to unnecessary or inappropriate medical services – or to services by providers who are not licensed or qualified to provide them.

Types of Health Care Fraud and Abuse

Health care fraud and abuse takes many forms. The most common of these forms include:

• Billing for services that were not provided
• Duplicate submission of a claim for the same service
• Misrepresenting the service provided
• "Upcoding" - charging for a more complex or expensive service than was actually provided
• Billing for a covered service when the service actually provided was not covered

• Using a member ID card that does not belong to that person
• Adding someone to a policy that is not eligible for coverage (i.e., grandchildren)
• Failing to remove someone from a policy when that person is no longer eligible (i.e., a former spouse)
• "Doctor shopping" - visiting several doctors to obtain multiple prescriptions.

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