New CMS Fraud and Abuse Program

The Centers for Medicare and Medicaid Services (CMS) recently released Fraud and Abuse compliance guidelines for small providers creating yet another regulatory burden for healthcare providers. These guidelines are intended to ensure that all care rendered is medically necessary and properly documented, as well as ensure that all care billed is within preferred practice guidelines and without outside influence. This might seem intuitive, and you might think that providers already do that, but it is estimated that fraud and abuse loss in the Medicare system was $65 billion in 2012. This has obviously become a concern for the federal government, so it should come as no surprise that the Office of the Inspector General (OIG) 2015 work plan includes 37 items (out of 111) related to fraud and abuse.

The “healthcare police” believe fraud and abuse is the number one issue in healthcare. So the OIG is going to be very active in the coming years and noncompliance could be very costly to your practice. In fact, one of the specific issues listed is increased investigation of ophthalmologists for inappropriate and questionable billing practices. This will be a big issue for optometry because we use the same codes.

CMS defines fraud as “knowing and willingly executing a scheme to defraud any healthcare benefit program”. Providers usually realize that they are committing fraud and are doing it intentionally to take money from the system.

CMS defines abuse as “actions involving medically unnecessary claims resulting in increased costs to the healthcare system”. Providers can often commit abuse without realizing it. Similarly, waste is defined as “over-utilization of services that result in unnecessary costs to the healthcare system”. As with abuse, providers often don’t even realize that they are committing waste and doing things that could put them in non-compliance with CMS’s program. Examples of Abuse and waste could include:

• Improper coding
• Inadequate medical records documentation
• Full glaucoma evaluations every six months on a patient simply because a distant relative has glaucoma
• Specular microscopy evaluation of a patient with a superficial corneal foreign body
• Referring a patient to a retinal specialist just because they are diabetic
• “Screening” your exam room for children with Medicaid to schedule them for exams
• Free CE from the center where you refer your cataract patients

Mistakes like these could be very costly for an optometry practice especially if the provider doesn’t realize they are committing fraud and abuse. Providers need to educate themselves and their staff about the new regulations and take steps to achieve compliance with the program. These steps include:

• Assigning a Compliance Officer and/or Compliance Contact
• Training doctors and staff • Establishing compliance standards
• Performing audits of medical records
• Correcting offenses
• Establishing internal disciplinary guidelines

Providers must have written compliance manuals and document staff training. Fortunately, TSO has partnered with OBS to provide complete materials and training at special TSO pricing. Fraud and abuse resources can be found at:
http:// shop.optometricbusinesssolutions. com/Fraud-and-Abuse_c62.htm.

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