Policy Manual sample

MDT Home Health Care Agency, Inc. FRAUD PREVENTION PURPOSE: To be in compliance with all Regulations and Laws. Prevent Fraud and Abuse. Reference: Billing Errors Most billing errors that providers make are not attempts to knowingly, willfully, or intentionally commit fraud. Some errors are the result of provider misunderstanding or pay adequate attention to Medicare/Medicaid/Insurance policy. However, other errors are a result of calculated plans to knowingly commit fraud for unjustified payment. When errors are identified, Medicare will take action commensurate with the error made. The agencies responsible for protecting Medicare will evaluate the circumstances surrounding the error and proceed with an appropriate plan of correction. In rare situations, if a provider has repeatedly submitted claims in error or has demonstrated gross disregard for Medicare conditions of participation, coverage, and payment policy, Medicare will seek legal action against the individual and /or organization. Medicare utilizes cost report auditing, fraud investigation, data analysis, and MR to detect potential payments errors. The results of data analysis indicate whether a situation is an error (pursued by the MR unit), potentially fraudulent (pursued by fraud investigators), or neither. Investigations may also be initiated by reports of improper activities reported by individuals, also referred to as “whistle blowers”. PROCEDURE: STRATEGIES TO PREVENT FRAUD AND ABUSE To be reduce payment errors, and best protect and strengthen our Agency, we use the follows four parallel strategies: · Preventing fraud through effective enrollment and through education of staff, partners, suppliers, and patients. · Early detection through internal audits and data analysis. · Close coordination with compliance officer, supervisors · Applying fair and firm enforcement policies. Anonymous Reporting: As employee of our Agency, we encouraged to them that they must report to us any suspect fraud activity that may include but not limited to: · Violation of schedule (not visit made as programmed) · Misrepresentation · Un-licensed services · Any kickback activity · Unnecessary services · Identity thief Home Health Agency Policies A-139