NHIC California Providers

Medicare fraud and abuse are important national topics. The U.S. General Accounting Office estimates that $1 out of every $10 spent for Medicare and Medicaid is lost to fraud. This translates into fewer resources for health care due to the strains on federal and state budgets. NHIC, Corp. has an aggressive program to combat fraud and abuse, but we need your help in reporting problems.

Fraud is the intentional deception or misrepresentation that an individual makes and knows to be false or does not believe to be true, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.

The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program.

The violator may be a physician or other practitioner, a hospital or other institutional provider, a clinical laboratory or other supplier, an employee of any provider, a billing service, beneficiary, Medicare carrier employee or any person in a position to file a claim for Medicare benefits.

Under the broad definition of fraud are other violations, including:

the offering or acceptance of kickbacks, and
the routine waiver of co-payments.

Fraud schemes range from those perpetrated by individuals acting alone to broad-based activities by institutions or groups of individuals, sometimes employing sophisticated telemarketing and other promotional techniques to lure consumers into serving as the unwitting tools in the schemes. Seldom do perpetrators target only one insurer or either the public or private sector exclusively. Rather, most are found to be defrauding several private and public sector victims, such as Medicare, simultaneously.

Monetary Results

During FY 2006, the Federal Government won or negotiated approximately $2.2 billion in judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings. The Health Care Fraud and Abuse Control account has returned over $10.4 billion to the Medicare Trust Fund since the inception of the program in 1997.

Enforcement Actions

In FY 2006, U.S. Attorneys' Offices opened 836 new criminal health care fraud investigations involving 1,448 potential defendants. Federal prosecutors had 1,677 health care fraud criminal investigations pending, involving 2,713 potential defendants, and filed criminal charges in 355 cases involving 579 defendants. A total of 547 defendants were convicted for health care fraud-related crimes during the year. Also in FY 2006, the Department of Justice (DOJ) opened 915 new civil health care fraud investigations, and had 2,016 civil health care fraud investigations pending at the end of the fiscal year.

In Medicare, the most common forms of fraud includes:

Billing for services not furnished
Misrepresenting the diagnosis to justify payment
Soliciting, offering, or receiving a kickback
Unbundling or "exploding" charges
Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment
Billing for a service not furnished as billed; i.e., upcoding

Helpful Links

Office of Inspector General (OIG) - The mission of the Office of Inspector General, as mandated by Public Law 95-452 (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs.
OIG Exclusion Database- The OIG maintains the List of Excluded Individuals/Entities (LEIE), a database which provides information to the public, health care providers, patients and others relating to parties excluded from participation in the Medicare, Medicaid and all Federal health care programs.
OIG Fraud Prevention and Detection- Basic information on fraud prevention and detection, including fraud alerts, regulations and compliance guidance.

04/17/2007