OIG Roundtable (Formerly Retro Fraud)

Eric, Matt, and Wade discuss a recent authority re-extended to CMS as it pertains to permissive exclusion authorities. While CMS had previously had such authority, OIG maintained this work since 1988. The ramifications and implications are broad.

Eric, Wade and Matt discuss how overwhelming participation can be at the premiere healthcare fraud conference can be, if you are not prepared. Proper planning, meeting scheduling, time management and not forgetting that you may be 3 hours in a different time zone can all affect how successful your attendance can be at this conference.

Eric and Wade discuss how CMS’ recent additions to the RAC audit protocols to include an additional 20 topics can have an implication on how plans run data, determine spikes and seek to resolve data inconsistences.

Eric, Wade and Matt discuss the huge disparity that can exist in healthcare fraud prosecutions that happen in state and federal courts. We discuss the importance of strong leadership to reward work, that is not necessarily tied to results. We also discuss the increases in healthcare costs and how members and payors need to work together to reduce the FWA in claims.

Eric and Matt discuss a recent policy disseminated by the DOJ that discusses the sub-regulatory role of policies in the government space (LCD/NCD). While these polices do not have the force of law or regulation, they are still seminal points to be relied upon from an investigative perspective.

MA plans are not required to reject claims from non-participating providers, while traditional Medicare requires providers to be enrolled in order to submit claims. This creates a huge FWA opportunity as there is no real way to vet the provider and the claims since there is no contractual relationship between the provider and payor (unless some state law or regulation establishes such a relationship via the submission of the claim itself).

Eric and Matt discuss a recent case where an individual engaged in identity theft and sought healthcare benefits under the stolen identity. This case is notable as the dollar amount was fairly low in comparison to other healthcare fraud matters, but demonstrates the aggressive approach the US Attorney’s Office is taken to curb FWA.

Eric and Matt discuss the Pig and the Python and how the influx of baby boomers will have an effect on SIU operations and staffing needs.

Eric and Wade discuss a recent indictment of a medical biller who engaged in a 6-year system Medicaid fraud scheme which included false billing for behavioral health providers, billing for deceased patients, incarcerated patients and patients that were under hospital care.

Eric, Matt and Wade discuss the often overlooked need to capture the right documents in an Incident To investigation. Catch phrases in requests for documents such as “including, but not limited to” can create confusion for providers. Get what you need the first time with some of our advice.