Anesthesia Experts blog concerning Anesthesia Billing and Collections
Author : Doc Clemens
In the past the government often relies on whistle-blowers and the False Claims Act to get at more complicated and subtle forms of fraud and abuse, and in healthcare allegations are often based on violations of the anti-kickback statue and the restrictions on physician self referral know as the Stark Law. The Justice Department credits the False Claims Act with returning 16.8 billion to HHS since 1986, when Congress reinvigorated the Civil War ear statue.
The CMS is now hard at work creating a giant, all knowing repository of claims and payment data from all federal health programs. It’s a tool the government believes will help rein in the massive amount of money spent on claims that are wasteful or flat out criminal. The reason for this is because it is estimated that 3% of overall healthcare spending is lost to fraud. CMS has been working for several years to overcome this legacy of fragmented information which plays to the benefit of people who are gaming the system. In fact the government has dedicated $311 million to Medicare and Medicaid integrity efforts- which is a 50% increase and projects these efforts to save $2.7 billion over five years. By 2014, the CMS intends to have all claims data, including Medicaid, flowing to the integrated data repository, allowing the government to run analytics on hundreds of millions of data points to spot aberration and trends with a program dubbed One PI for program integrity.
A single Medicare contractor will collect and analyze claims data for all categories- physicians, hospitals, durable medical equipment, prescription drugs, home health and hospice-in each of seven zones covering the country, largely mirroring the jurisdictions of Medicare Administrative Contractors. These Zone Program Integrity Contractors, or ZPICs, will get raw claims as well as ones that have been paid or rejected. All of the data, meanwhile, are supposed to be assembled in formats compatible with a single platform, closing the door on a fragmented jumble of claims data produced by Part A fiscal intermediaries and Part B carriers.
Investigators look for claims that don’t make sense, and then providers or companies that submitted them get a call or visit form government agents curious to see if there’s a reasonable explanation and whether there’s even a real, functioning business at the address listed. After a scheme is identified, investigators look for new leads by puling claims made by the companies, providers and beneficiaries involved in a scam.
The meaning of all of this is to please tell your providers not to do anything that is even close to fraud and abuse. This new data which will review all claims from each provider will find any and all statically deviations compared to the national data from the other anesthesia providers.