Compliance TODAY October 2013 a publication of the health care compliance association www.hcca-info.org Why compliance matters to the enforcement community Loretta Lynch U.S. Attorney, Eastern District of New York See page 16 27 Medicaid vs. Medicare claims audit appeals: A road less clear Cornelia M. Dorfschmid and Lisa Shuman 35 41 47 Sunshine Act reporting: Minimizing consulting and royalty payment risks OIG issues updated guidance on exclusion: What it means for providers Be part of the solution: Stop medical identity fraud Stephanie J. Kravetz Lester J. Perling Marita Janiga This article, published in Compliance Today, appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests. Feature by Marita Janiga Be part of the solution: Stop medical identity fraud »» Medical identity fraud can be very costly and very risky if patient records are comingled. »» The lasting effects of medical identity fraud can be mentally taxing. »» It can take years for a victim’s record to be cleared up. »» Asking for personal identification during time-of-service can reduce the risk of fraud. Marita Janiga ([email protected]) is Executive Director of National Special Investigations & Compliance Hotline, Kaiser Permanente, National Compliance, Ethics & Integrity Office in Oakland, CA and former Special Agent in Charge, United States Department of Labor, Office of Inspector General, Office of Labor Racketeering and Fraud Investigations. W Janiga e’ve all seen those television commercials for identity (ID) fraud. They go something like this: “Your 85-yearold grandmother has been having a ball on her new mountain bike—at least that’s what it looks like she’s doing when you review her credit card statement.” Many people never imagine they can be a victim of identity fraud or think of the consequences until it happens to them. Some criminals steal your identity only to rack up credit card charges, others can do major damage. The term identity theft can also include medical identity theft or fraud, which can be even more costly than just buying a new mountain bike. Medical identity theft In its “Third Annual Survey on Medical Identity Theft,” the Ponemon Institute reports that medical identity theft numbers continue to rise in the United States and estimated that in 2012, 1.85 million people were affected by the crime, at a cost of $41.3 billion.1 Medical identity fraud is of particular concern to the senior population who are often specifically targeted by identity thieves. Medical identity fraud occurs when a person’s identity is used by someone else to obtain medical treatment and/or medications. As previously mentioned, medical identity fraud can be very costly, leading to higher premiums and overall healthcare costs. The Centers for Medicare & Medicaid Services (CMS) is focusing a lot of attention on the subject, educating its beneficiaries on various fraud schemes and how to protect themselves from becoming victims of identity fraud. CMS literature cautions its beneficiaries to never give out their Social Security, Medicare, health plan, and banking numbers or information to someone they don’t know and to carefully review their plan statements to ensure that all the information is correct. Examples of medical identity theft identified by CMS include: ·· Someone other than the member using a member’s ID card without the member’s knowledge. ·· A member giving their medical ID card to someone else to use—often called “card sharing.” ·· Vendors or providers billing for treatment or service that was never rendered to a member. 888-580-8373 www.hcca-info.org Compliance Today October 2013 »» Educating beneficiaries on fraud schemes can protect them from becoming victims. 47 Feature In addition to being costly, the lasting effects of medical identity fraud can also be mentally taxing. In November 2012, Tech Blog ran an article titled “How Medial Identity Theft Can Give You a Decade of Headaches.”2 The victim, Arnold Salinas, reported that he knew a lot about the person who stole his identity—5-foot-9, 190 pounds, liked pizza and paid for it with forged checks, drove fast and racked up a lot of speeding tickets, and worst of all, he was sick and sought medical care in Salinas’s name. Salinas has been dealing with identity fraud since 2002 and still fears that he may go to the hospital and be treated based on the thief’s medical information—a mistake that could potentially cost him his life. Preventing and detecting medical identity fraud Medical personnel can play a key role in safeguarding patients and personnel from identity theft by taking the following steps. ·· Follow an ID protocol when registering a patient or member. This is the best way to ensure that the right care is being delivered to the right person. ·· Ask for the patient’s member ID card and a photo ID card. The best photo ID is a government-issued card, such as a driver’s license, a military ID card, a passport, or a residency card. ·· If a patient has no photo ID, quietly and privately ask them to provide demographic information such as date of birth, home address, phone number, and/or the subscriber’s name on the health plan. There are many ways to help mitigate the risks of medical identity fraud. Talk to your supervisor to see if there are immediate resources readily available for your use. Be part of the solution. Stop medical identity fraud before it happens. 1.Ponemon Institute. Third Annual Survey on Medical Identity Fraud. June 2012. Available at http://www.ponemon.org 2.Robertson, Jordan: “How Medical Identity Theft Can Give You a Decade of Headaches.” Bloomberg News, November 7, 2012. Available at http://bloom.bg/15UagcL SCCE/HCCA 2012–2013 Board of Directors EXECUTIVE COMMITTEE Shawn Y. DeGroot, CHC-F, CCEP, CHRC SCCE/HCCA President | Associate Director, Navigant Consulting, Denver, CO John Falcetano, CHC-F, CCEP-F, CHRC, CHPC, CIA, CICA SCCE/HCCA Vice President | Chief Audit/Compliance Officer, Vidant Health, Greenville, NC Gabriel L. Imperato, JD, CHC SCCE/HCCA Second Vice President | Managing Partner, Broad and Cassel, Fort Lauderdale, FL Sara Kay Wheeler, JD, CHC SCCE/HCCA Treasurer | Partner, Attorney at Law, King & Spalding, Atlanta, GA Urton Anderson, PhD, CCEP SCCE/HCCA Secretary | Director, Von Allmen School of Accountancy, Gatton College of Business and Economics, University of Kentucky Sheryl Vacca, CHC-F, CHRC, CCEP, CHPC, CCEP-I Non-Officer Board Member | Senior Vice President and Chief Compliance and Audit Officer, University of California, Oakland, CA Frank Sheeder, JD, CCEP SCCE/HCCA Immediate Past President | Partner, Attorney at Law, DLA Piper, Dallas, TX Ex-Officio Executive Committee Roy Snell, CHC, CCEP-F Chief Executive Officer, SCCE/HCCA, Minneapolis, MN Keith Halleland, Esq., CCEP, CHC SCCE/HCCA Legal Counsel | Halleland Habicht, PA, Minneapolis, MN Board Members Deann M. Baker, CHC, CCEP, CHRC Sutter Care at Home Compliance Officer, Sutter Health, Fairfield, CA Catherine Boerner, JD, CHC President, Boerner Consulting, LLC, New Berlin, WI Brian G. Flood, JD, CHC, CIG, AHFI, CFS Partner, Husch Blackwell LLP, Austin, TX Margaret Hambleton, MBA, CPHRM, CHC, CHPC Senior Vice President, Ministry Integrity, Chief Compliance Officer, St. Joseph Health System, Orange, CA Debra Hinson, MBA, RRT, CHC, CCEP, CHRC President & CEO, Compliance Consultants, Inc., Mineral Bluff, GA Robert A. Hussar, JD, CHC Counsel, Manatt, Phelps and Phillips, Albany, NY Jenny O’Brien, JD, CHC, CHPC Chief Medicare Compliance Officer, UnitedHealthcare Medicare & Retirement, Minnetonka, MN Robert H. Ossoff, DMD, MD, CHC Assistant Vice-Chancellor for Compliance & Corporate Integrity, Vanderbilt University Medical Center, Nashville, TN Daniel Roach, JD General Counsel, Optum360, San Francisco, CA Lori Strauss, RN, MSA, CPC, CPC-H, CHC, CHP, CHPC Chief Corporate Compliance & Privacy Officer, University of Virginia Health System, Charlottesville, VA Debbie Troklus, CHC-F, CCEP-F, CHRC, CHPC, CCEP-I Managing Director, Aegis Compliance and Ethics Center, Chicago, IL 888-580-8373 www.hcca-info.org Compliance Today October 2013 ·· Someone using another person’s Social Security number to obtain a medical ID card. ·· People using a member’s Medicare or health plan number for reimbursements of services never received. ·· People calling the member to ask for a Medicare or health plan number. 49
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