Fraud and Abuse Risk Assessment
All too often physical therapists do not consider themselves at risk for penalties related to fraud and/or abuse, simply because they do not understand how their typical day to day behaviors may be viewed as fraudulent or abusive by today's federal standards. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit, such as billing for services that are not rendered. Services that are billed but not documented are generally considered as not being rendered and therefore could constitute fraud. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with intent to deceive the insurer.
For a variety of historical reasons, physical therapy and rehabilitation providers are at the center of many investigations and policy decisions regarding fraudulent and abusive practices. Most therapists and hospital administrators do not realize that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) included significant fraud and abuse provisions contained in the legislation. The Act makes "knowingly and willfully" defrauding any health care benefit program a federal crime. In fact, there are over 15 federal fraud laws that could be applied to health care providers, including physical therapists. Specifically, compliance issues that put physical therapy providers at risk include billing for services not documented, unbundling, upcoding, lack of documentation to support billing of timed codes, failure to properly use modifiers and waivers, submitting claims for medically unnecessary services, and care that is below the Standards of Care.
Fearon & Levine can assist in assessing your risk associated with potential fraud and/or abuse practices and support your Compliance Literacy through:
- Assessment of risk for key fraud and abuse areas in physical therapy
- Assessment of risk for key fraud issues related to the Federal False Claims Act
- Identification of risk related to over 15 federal criminal fraud statutes
- Identification of risk related to various CMS and other agency programs
- Identification of risk related to potential Stark ramifications in the areas of ownership, self referral, joint venture's, fee splitting, kickbacks, or inducements
- Developing a plan to minimize or eliminate behaviors that put the provider at risk for fraud or abuse investigations
- Assistance with incorporating physical therapy professional standards, guidelines, and positions into practice policies and procedures
- Staff education and training in justification of medical necessity and relationship to fraud and abuse activity
- Education and training in minimizing risk of fraud and abuse behaviors
- Assist in identifying when an employer is responsible for the acts of an employee under the Federal False Claims Act
- Education regarding ongoing developments in officer liability relating to "piercing the corporate veil"
- Education regarding the criminal anti-kickback law and the government's application of this law to physical therapy practices