Guide to Medicare Ethics

Healthcare Law -- Ethics & Policy Memo to ABC Hospital Board of Directors: How to develop strategies to help mitigate abuse and fraud within our organization by understanding fraud and abuse issues. The Department of Health and Human Services has provided a great deal of good information for healthcare professionals and the public in terms of ways to avoid and/or deal with fraud and abuse. This document reflects the ways in which this hospital can be on the lookout for fraud and abuse when it comes to Medicare.

This document will also explain the difference between fraud and abuse in the Medicare system. Medicare Fraud Typically Medicare fraud means a person in this hospital -- or a doctor affiliated with this hospital contractually -- would knowingly submit false statements or somehow misrepresent what his or her services actually were, in an attempt to cheat the federal government. Also a healthcare person could solicit, pay and/or accept remuneration in order to reward a person who has, through fraud, been reimbursed by federal programs.

It is incumbent on this hospital to meet with and train the entire staff at all levels as to the importance of honesty and forthrightness with regard to all billing issues. We need to develop strategies -- using the best minds and the strong leadership from senior staff -- to not only be aware of Medicare fraud, but to make sure we prevent it happening. It is also very important to remember that anyone can commit healthcare fraud. So watchfulness is an absolute imperative.

If anyone suspects fraud or notices something suspicious occurring, a red siren should go off in that person's head -- if, that is, leadership at this hospital has properly trained staff.

Examples of Medicare fraud include: a) "Knowingly billing for services not furnished, supplies not provided, or both, including falsifying records…" that reflect the bogus delivery of services and items, or appointments that a patient did not keep; and b) "Knowingly billing for services" that were higher in terms of the level of complexity than the service that was actually provided or documented in the patient's files (H&HS). Medicare Abuse Medicare abuse is similar to Medicare fraud, with several distinct differences.

Medicare abuse includes practices that "are not consistent with the goals of giving patients "medically necessary" services that use "professionally recognized standards that are priced fairly" (H&HS). Typically, Medicare abuse includes the following: a) Billing for services that were not medically appropriate; b) charging excessive fees for supplies that are supposed to be part of a patent's care; and c) "Misusing codes on a claim, such as upcoding or unbundling codes" (H&HS).

Anyone who is part of this staff who engages in illegal acts as outlined above will be exposed as being involved in criminal activity with civil liability. Typical False Claims (prohibited by the False Claims Act (FCA) include: a doctor submits a claim to Medicare based on a higher level of medical services that were actually provided. The penalty we should point out to our staff ranges from fined of $5,500 to $11,000, and criminal penalties can go farther than that.

Anti-Kickback Statue (AKS): this law makes it a criminal offense to "knowingly and willfully offer, pay. Solicit, or receive any remuneration" for services or items that are reimbursable from Medicare. Typical example: a.