Avoiding Coding and Billing Errors: Detecting and Reporting Fraud, Waste, and Abuse
Louise Lindsey, Editor
All Skilled Nursing Facility (SNF) employees should take an active part in preventing, detecting, and reporting potential fraud, waste, and abuse (FWA). They should also comply with the applicable statutory and regulatory requirements, including adopting and using an effective compliance program. This is to protect themselves and the facility from potential damage.
Standards of Conduct should describe the SNF’s expectations that all employees conduct themselves in an ethical manner, and that appropriate mechanisms are in place for anyone to report noncompliance and potential FWA.
Employees also have a duty to the Medicare Program to report any compliance concerns and suspected or actual violations of which they may become aware. This reporting obligation should be mentioned in the facility’s Code of Conduct.
There are a number of ways in which an individual can prevent FWA. These include being on the lookout for suspicious activity, conducting themselves in an ethical manner, ensuring accurate and timely data and billing, verifying all received information, and being aware of all FWA policies and procedures.
Potential issues can include whether or not:
- A provider’s prescriptions are appropriate for a resident’s condition
- The services being provided are medically necessary
- The level of service being provided is above or below the minimum required
Other issues which can easily be spotted by an alert employee include drug diversions, the use of expired drugs, the dispensing of generic drugs when a prescription specifically requires branded drugs; obvious alterations on prescriptions, medical records, or laboratory tests; and multiple identical prescriptions, possibly from different doctors.
All potential FWA concerns should be reported by staff to the organization’s compliance department, which is also obligated to investigate and make a determination on every allegation. There should also be a means to report potential FWA instances through an anonymous channel.
FWA can also be reported directly to the HHS Office of Inspector General (OIG) by using the toll-free number 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950, Fax: 1-800-223-8164, or by email at HHSTips@oig.hhs.gov. Tips can also be made online at Forms.OIG.hhs.gov/hotlineoperations/index.aspx.
Once an episode of FWA has been detected, the facility is under an obligation to promptly correct it. Correcting the problem saves the government money and ensures compliance with CMS requirements.
All SNFs must have a prepared corrective plan ready which can be adapted to resolve the issue. The actual plan will vary, depending on the specific circumstances. The corrective action plan should address the underlying problem which caused the violation to prevent future noncompliance.
The adapted plan must also include timeframes for specific actions. All corrective actions must be documented, include consequences for the failure to satisfactorily complete the corrective action, and be continuously monitored to ensure their effectiveness.
Corrective actions may include adopting new prepayment edits or document review requirements, conducting mandated training, providing educational materials, sending warning letters, or taking disciplinary action, such as terminating an employee or provider.
The facility is obligated to report any FWA errors within 60 days of detection, and to conduct a full investigation and report back within six months. In this regard, if should be remembered that failure to act after being alerted is regarded as a breach by the OIG, and more than one facility administrator has lost their license in this way. CMS operates a six year “look back” period, so it is important to keep all records for at least that period of time.
