EDUCATION & TRAINING PROGRAMS

Provider Fraud Consultants, Inc. (PFC)

Daniel J. Osborne, M.S., Founder & President

18065 238th Street, Tonganoxie, KS  66086

(913) 669-6987     cccpfc@gmail.com

Health Care Fraud & Abuse

· Causes, Types & Examples

· Practice TIME BOMBS & Fraud Target Danger-Zone

· Responding to Investigations

· Detecting fraud & emerging schemes

· Establishing evidence of fraud to support prosecutions

Health Care Laws & Rules

· Administrative, Civil & Criminal

· Prosecution Burden of Proof

· Medicare & Other payor requirements

· Federal Statutes, Civil/Criminal

Documentation

· Standards & Documentation Musts

· In the file, outside the file

· Exams, Reports & Encounter Notes, Forms

Coding & Billing

· ICD-9-CM, HCPCS & CPT-4

· CMS-1500

· Fee Guidelines

Health Care Compliance

· Overview & Benefits

· Standards for ‘Effective’ Compliance

· Steps for Success

· LINKS to ‘key’ web-sites

Test Your Knowledge on Health Care Fraud / Abuse & Compliance

Answer the questions by indicating TRUE or FALSE.  No ‘trick questions’, only one correct answer!

1. The ‘crime scene’ for health care provider fraud investigations are the clinical and billing records of the health care provider.  True  False

2. Patients provided promised ‘free consults’ by doctors should not be billed by the doctor for a New Patient Exam.  True  False

3. Inadequate documentation of services rendered is a leading cause for discipline of health care providers by regulatory boards.  True  False

4. ICD-9 codes are reported as a first step in establishing medical necessity when seeking third party reimbursement.  True  False

5. The appropriateness of health care practice activity is best determined by ‘everyone is doing it’ and/or ‘it is getting paid’. True  False

6. Investigators mining for investigative targets frequently review the marketing practices of health care providers.  True  False

7. When billings for health care services are submitted, the provider is not only indicating the services and billing amounts but also that the services were appropriately administered and were completely and accurately documented in the patient’s clinical record.  True  False

8. Reduction or waiver of fees based on financial hardships should only be provided after hardship is verified and documented.  True  False

9. The accuracy of ALL services reported/billed is the responsibility of the provider identified on claims and billing statements.  True  False

10. A first step for implementing a ‘formal’ compliance program is a baseline practice audit by an experienced auditor.  True  False

11. A key for successful prosecutions is the prosecutor having ‘story-tellers’ who tell what happened and who did it.  True  False

12. Marketing efforts of health care providers are not only seen by the targeted audience but also by investigators, and inappropriate marketing practices can lead to investigations.  True  False

13. ‘Time of Service’ discounts should only be offered to patients that have limited or no insurance coverage.  True  False

14. The term ‘provider’ as found in CPT indicates ‘physician or therapist’ -  appropriately licensed health care provider.  True  False

15. Health care fraud investigators are not interested in health care providers who are trying to do it right but only in those providers who purposefully and knowingly do it wrong.  True  False

ANSWERS: 1.True,  2.True,  3.True,  4.True,  5.False,  6.True,  7.True,  8.True,  9.True,  10.True, 11.True,  12.True,  13.False,  14.True,  15.False, 

16.True,  17.False,  18.False,  19.True,  20.True,  21.True,  22.False,  23.True,  24.False,  25.False,  26.False,  27.True, 28.True,  29.False,  30.False

16. A critical part of a health care fraud investigation is the interview of patients to determine if they received the services billed and who provided the services.  True  False

17. Providers not treating Medicare beneficiaries need not be concerned about Medicare laws & rules.  True  False

18. Clinical notes by providers should be more extensive for patients having insurance than for those who pay cash.  True  False

19. An indicator of inappropriate billing practices by providers could be the provider not knowing what acronyms CPT and ICD-9-CM stand for.  True  False

20. Standards to determine if a compliance program is ‘effective’ are found in the Federal Sentencing Guidelines.  True  False

21. Unlicensed staff following provider instructions can be prosecuted if their conduct was found to have been unlawful.  True  False

22. Health care regulatory boards set payment standards for health care services that ALL payors must follow.  True  False

23. Providers using ‘CPT coding’ are reporting amount of work done, judgment used, and medical risks of patients.  True  False

24. Limited license providers do not need the complete CPT coding manual as most CPT codes do not apply to them.  True  False

25. It is sufficient, as part of compliance process, to just stop identified unlawful activity without taking other remedial actions.  True  False

26. Convicted felons offer the best source of information for health care providers for advice on implementing and administering health care compliance programs.  True  False

27. One of the more significant aspects of ‘HIPAA’ were provisions to enhance prosecutions of health care fraud.  True  False

28. Not following terms of payor contracts could result in providers not getting paid as well as their becoming a fraud investigative target.  True  False

29. All compliance activity should be ‘attorney-client privileged’ and protected from disclosure to outside parties.  True  False

30. Health care providers going to a “cash” practice are immune from the increased efforts of fraud investigators looking for misconduct and violations of law.  True  False

PFC Affords Health Care Professionals, Regulators, Insurers,

Law Enforcers and Others with Timely, Insightful

and Diverse Education & Training Programs

“… has taught thousands, to include FBI agents, State Highway Patrol officers, local law enforcement, Assistant US Attorneys, physicians, surgeons, chiropractors, PTs, Special Investigation Unit (“SIU”) agents, to name but a few, how to detect, prevent, investigate, and successfully prosecute healthcare fraud and abuse.  Dan (PFC) has assisted providers across the Country in developing bona fide Healthcare Compliance programs.  He has also worked closely with numerous Boards of Examiners, Malpractice carriers and others to minimize exposure to healthcare fraud and abuse”.  Thomas Rhudy, D.C., J.D.  Read More

Don’t throw your money down the drain with

ineffective education & training…  Contact PFC for effectual instruction, guidance & coaching

Call 913-669-6987 or email cccpfc@gmail.com for a ‘confidential’ Free Consultation

 

See Below to

‘Test Your Health Care Fraud & Compliance Knowledge’ 

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