Policy Manual sample

MDT Home Health Care Agency, Inc. Definition of Fraud Health care fraud is defined in Title 18, United States Code U.S.C.) & 1347, as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. Examples of Fraud Fraud may take such forms as: · Incorrect reporting of diagnoses or procedures to maximize payments. · Billing for services not furnished and/or supplies not provided; this includes billing Medicare for appointments that the patient failed to keep. · Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service or billing both Medicare and another insurer in an attempt to get paid twice. · Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount. · Soliciting, offering, or receiving a kickback, bribe, or rebate (e.g., paying for referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment) · Unbundling or “exploding” charges. · Completing Certificates of Medical Necessity (CMNs) for patients not personally known by the provider or supplier. · Billing based on “gang visits” such as a physician visiting a nursing home and billing for 20 nursing home visits without furnishing any specific service to individual patients. · Misrepresentations of dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services. · Billing non-covered or non-chargeable services as covered items. · Using another individual’s Medicare Health Insurance card to obtain medical care. Examples of Cost Report Fraud Examples of cost report fraud may include: · Incorrectly apportioning costs on cost reports. · Including costs of non-covered services, supplies, or equipment in allowable costs. · Arrangements by providers or suppliers with employees, independent contractors, suppliers, and other that appear to be designed primarily to overcharge the program through various devices (commissions, feesplitting) to siphon off illegal profits. · Billing Medicare for costs not incurred, or costs that were attributable to non-program activities, other enterprises, or personal expenses. · Claiming bad debts without first genuinely attempting to collect payment. · Amounts paid to owners or administrators that have been determined to be excessive in prior cost report settlements. Home Health Agency Policies A-141