What is health care fraud?
Health care fraud is an intentional deception or
misrepresentation that the individual or entity makes knowing
that the misrepresentation could result in some unauthorized
benefit to the individual, or the entity or to some other party.
The most common kind of fraud involves a false
statement, misrepresentation or deliberate omission that is
critical to the determination of benefits payable. Fraudulent
activities are almost invariably criminal, although the specific
nature or degree of the criminal acts may vary from state to
state.
The variety of fraudulent reimbursement and
billing practices in the health care area is potentially
infinite. The most common fraudulent acts include, but are not
limited to:
-
Billing for services, procedures and/or
supplies that were never provided or performed
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Intentionally misrepresenting any of the
following, for purposes of obtaining a payment—or a greater
payment—to which one is not entitled:
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The nature of services, procedures and/or
supplies provided or performed;
-
The dates on which services and/or treatments
were rendered;
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The medical record of service and/or treatment
provided;
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The condition treated or the diagnosis made;
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The charges for services, procedures and/or
supplies provided or performed;
-
The identity of the provider or the recipient
of services, procedures and/or supplies.
How big is the problem?
The United States spends more than $2 trillion
on health care every year. Of that amount, NHCAA estimates
conservatively that at least 3%--or more than $60 billion each
year--is lost to fraud. This loss directly impacts patients,
taxpayers and government through higher health care costs,
insurance premiums and taxes. Additionally, health care fraud
often hurts patients who may be subjected to unnecessary or
unsafe procedures or who may be the victims of identity theft.
Source:
http://www.nhcaa.org
Federal Fraud Enforcement and
Compliance Planning
The following is an overview of Federal Fraud
Enforcement and Compliance Planning.
Learn more detailed information.
Any individual or entity providing
health care services and submitting a claim for
payment by the federal government must be alert to the
potential for liability stemming from an
inappropriately submitted claim. The federal
government has the authority to investigate the
claim's propriety and the authority to impose
sanctions where an investigation finds fault with a
claim, ranging from a possibly inadvertent mistake to
a determination that the claim was fraudulently
submitted. This document provides the skeleton for how
physicians and other health care professionals can
acknowledge and proactively address the federal fraud
enforcement environment through the establishment of a
compliance plan.
The existence of an effective
compliance plan provides evidence that any mistakes
were inadvertent, and this evidence would be
considered in determining whether a medical practice
or other health care entity has made reasonable
efforts to avoid and detect misbehavior. A compliance
plan also will identify under-coding and improve
communications within a practice setting. An effective
compliance plan should include the following 7
elements:
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A clear commitment to compliance.
A compliance plan must ensure that everyone in the
organization understands the obligation to comply
with established and understood standards, and that
the organization will take actions to uphold those
standards.
-
Appointment of a trustworthy
compliance officer with a high level of
responsibility. The compliance officer will be
considered to have the requisite authority if he or
she is able to influence behavior and organizational
practices.
-
Effective training and education
programs. There must be a routine training and
education process that addresses the role of
everyone involved in the organization and makes
participation in the compliance program
understandable.
-
Auditing and monitoring.
There must be a regular review of the organization's
claim development and submission process, starting
from the point where a service for a patient is
initiated through the submission of a claim for
payment. The monitoring process includes a
methodology to facilitate employee reporting of
suspected situations of fraud or abuse.
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TRAINING
Association of Certified Fraud Examiners
Advanced Fraud Examination Techniques
Austin, Texas
October 1-3, 2007
Tampa Bay Chapter
September 11, 2007
"Best
Practices versus Challenges for a Corporate Health-Care
SIU"
Clark J. Bolton, CFE
Michael J. Kotch, CFE
October 16, 2007
"Securities Fraud"
Bruce W. Barnes, P.A.
January 8, 2008
T.B.A.
T.B.A.
February 12, 2008
T.B.A.
T.B.A.
March 11, 2008
T.B.A.
T.B.A.
April 8, 2008
T.B.A.
T.B.A.
9th Annual Fraud & Computer Crimes Seminar
May 6-7, 2008
Ruth Eckerd Hall
Clearwater, Florida
1111 McMullen Booth Road
Clearwater, FL 33759
2006 - 2007
OFFICERS &
DIRECTORS
PRESIDENT
Christine Dever, CPA, CFE
Accountabilties Consulting Services
(813) 417-1825
VICE PRESIDENT
Steve Hooper, CIA, CFE, CCSA
Clerk of the Circuit Court Hillsborough County, FL
(813) 276-2029 x3703
SECRETARY
Clark J. Bolton, CFE
WellCare Health Plans, Inc.
(813) 290-6200 x5128
TREASURER
Laura Krueger Brock, CPA, CFE
Kirkland, Russ, Murphy & Tapp, P.A.
(727) 572-1400
DIRECTOR
Mark Dubina,
CFE
Florida Department of
Law Enforcement
(813) 878-7366
DIRECTOR
Ellen Wilcox, CFE
Florida Department of
Law Enforcement
(727) 298-2482
DIRECTOR
Gary Chapman, CFE, CGAP
City of Tampa, Internal Audit
(813) 274-7163
CHAPTER TRAINING
Wayne Boytim, CFE
City of Tampa,
Internal Audit
(813) 274-7167 |
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Communications. Organizations must
maintain an effective communications process, including a
"hotline" procedure to facilitate reporting of suspected
violations.
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Internal investigation and enforcement.
Organizations must be able to conduct an appropriate
investigation and take disciplinary actions.
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Response to identified offenses and
application of corrective action initiatives. On the
identification of a compliance problem, organizations have a
responsibility to take demonstrable corrective actions,
including steps to prevent further similar offenses.
Documentation is a central component of an
effective compliance plan. Accurate documentation on the
operation of the compliance plan and of patient records is
crucial. Medical record information provides the justification
necessary to support claims payment. The medical record may be
used to validate the site of the service, the medical necessity
and appropriateness of the diagnostic and/or therapeutic
services provided, and that the services have been reported
accurately.
Source:
http://www.ama-assn.org
News from the ACFE
Advanced Fraud Examination Techniques
As you are
already aware, fraud affects businesses and government entities
of all shapes and sizes. We know the key to reducing fraud is
through prevention programs and continuing education, which
helps you understand the issues and the impact legislation has
on the fight against fraud. I encourage and challenge you to
kick off a campaign to fight fraud to your local area. In
October, the ACFE will hold its annual
Advanced
Fraud Examination Techniques course in Austin, TX at
the Omni Hotel. This is an advanced level fraud examination
course directed at teaching you complex behaviors in fraud
prevention and detection. This class is a uniquely interactive
learning environment where you will work on an actual fraud case
that has been modified for this teaching purpose. By
understanding how it feels to be part of a small team working a
real investigation, this will enhance your skills as a fraud
examiner and expand your capabilities.
ACFE Seal Usage Policy
Who May Use
the Seal?
Only
Certified Fraud Examiners in good standing are entitled to use
and display the seal. Associate members may not use the seal.
How May CFEs
Display the Seal?
Displaying
the seal on a web page or on company letterhead
-
The seal
may only be displayed on a company’s web site or letterhead if
that company employs at least one Certified Fraud Examiner in
good standing on a full-time basis.
-
The seal
may not be used to imply that ACFE endorses the company. For
example, if the seal were displayed prominently next to the
company’s name or logo in such a way that it appears the
company and ACFE have some sort of business relationship or
endorsement, this would be improper.
The seal may
only be displayed in such a way as to represent that one or more
employees of the company are Certified Fraud Examiners in good
standing.
-
The seal
may not be used to imply that a person is a Certified Fraud
Examiner in good standing if that person really isn’t. For
example, if the seal were displayed near the name of a person
who is not a CFE in good standing, in such a way that it
appears that the seal is connected to that person’s name, then
this could cause the public to believe that the person is a
CFE. That would be improper.
-
Decisions
about whether a company’s use of the seal is proper will be
made on a case-by-case basis.
Displaying
the seal on a business card
How Can CFEs
Determine if They Are Using the Seal Properly?
If CFEs have
any questions about how to use or display the seal, they should
contact Helen Pryor at the ACFE’s world headquarters. They can
also send a copy of their proposed letterhead, business card,
web site, etc. to
hpryor@ACFE.com and we will review it and let them know if
it meets our approval. |
Chapter News
New Certified Fraud Examiners
 Hats
Off! to our newest CFEs:
Debbie Venanzio,
Corporate Investigator, Branch Banking & Trust Co.
Jewel Bridgeman,
Consultant, Booz Allen Hamilton
Glenda
Eichholtz, Fraud Detective, Polk County Sheriff's Office.
New Chapter Members, Associates, & Affiliates
| Gary Cook |
Professor |
Florida Southern College |
| Leanne Cross |
Audit Manager |
CPA Associates |
| Jan Decker |
Financial Analysit |
Federal Bureau of
Investigation |
| Deborah Drake |
VP/ Sr. Corporate
Investigator |
Mercantile Bank |
| Lorri Ericson |
Partner |
Harper, Van Scoik & Co., LLP |
| Robert Goot |
Fraud Product Manager |
Fidelity National Information
Services |
| Robert Jones |
|
HSBC Mortgage Services |
| Mitch Roop |
CEO |
Mitch Roop, Inc. |
| Sharon Shaw |
Construction Specialist |
MSM Corporation |
| Minerva Vasquez-Farmer |
Audit Manager |
Bobbitt Pittenger & Co. |
| Ken Walton |
Sr. Internal Auditor |
MOSAIC |
| Mary Wilson |
Director of Compliance &
Internal Audit |
Highlands County Clerk of
Courts |
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Dinner Meeting News
Our
next Dinner Meeting is scheduled for September 11th
 Michael J. Kotch, CFE, and Clark J. Bolton, CFE,
will present "Best
Practices versus Challenges for a Corporate Health-Care
Special Investigation Unit (SIU)." Mike is the Director,
Corporate SIU for WellCare Health Plans. He is a Certified
Fraud Examiner and a Certified
Compliance Professional. Mike has over 20 years experience
and was a criminal investigator with the US Army. Clark is
the Supervisor of Investigations/SIU for WellCare Health
Plans. He is a Certified
Fraud Examiner
and the current
Secretary of ACFE Tampa Chapter. He has 16
years of criminal, civil and regulatory investigative and
managerial experience in public & private sector
and 9
years experience dedicated to P/C & Health Care insurance
fraud investigations.
The dinner meeting will be held at the Westshore
Hotel, located at 1200 N. Westshore Blvdd.
in the Hyde Park Room (first floor). The hotel
is just north of I-275 and Cypress Avenue on the east side of
Westshore (map). Evenings will begin with a social at 6:00 P.M.,
followed by a buffet dinner at 6:30 and a presentation at 7:00. The
cost is $20, payable at the door.
To make your reservation, please use the following link
Chapter
Meeting Reservation and complete the form at the bottom of
the page. You can also make your reservation by emailing
Wayne
Boytim or calling him at (813) 274-7167 by the Friday before the
meeting date. Reservations will be accepted after that date and
walk-ups are always welcome. Please remember that cancellations are
accepted up to the afternoon of the meeting. No shows will be billed
after the second missed meeting. Please help us keep our costs down
by letting us know if you are unable to attend. |
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Federal Fraud and Abuse Laws
Fraud
and Abuse Statutes
Health
Care Program Administration Statutes
HIPAA Criminal Statutes
Source:
http://www.ama-assn.org |
West Florida Chapter ISACA Training
An upcoming seminar on November 12, beginning at
08:00am will feature a convicted felon, Sam E. Antar, who some
of you may remember from the “Crazy Eddie’s” scandal in the
1980’s. Sam, a former CPA and CFO of Crazy Eddie’s in New York,
will tell us how he and his colleagues perpetrated one of the
largest white collar fraud crimes in SEC history. More
information can be found at his web site:
www.whitecollarfraud.com. In addition to Mr. Antar, we will
have representatives from Carnegie Mellon’s CERT Coordination
Center on the same day giving us information on how to recognize
and mitigate insider threat activities. This one-day event, to
be held at the Quorum Hotel in the Westshore area of Tampa, will
provide 8 CPE’s for only $175.
Register for this seminar at:
https://www.acteva.com/go/westflisaca |
President's Message
A new season is upon
us. We had an excellent Chapter turnout at the National ACFE
conference in Orlando in July. Thank you to all of you that
attended. We tried to get together with as many of the members
as possible, however, the tracks of sessions were packed out and
the schedule was very tight. I hope you all were pleased with
the conference and we would love to hear your thoughts on
topics, speakers and the general event itself either via email
or at the dinner meetings. The National Conference will be in
Boston next year, mid July.
The board met over
the summer and we are on our way to accomplishing many goals
this year but we cannot do it without you! Listed below are
some of those goals:
-
We will be entering our application for Chapter of the
Year. Many of you participate in activities currently that can
be highlighted in that application. Our new secretary Clark and
I will be contacting some of you to gather as much information
for this. If you have spoken at seminars, groups or done
internal training on fraud, please email us and let us know
that. If you work with the community in your capacity of your
career or in the capacity of a CFE please email us the details.
We came really close to winning it two years ago. Due to
personal issues of the team we were not able to apply last
year. I am very confident that we have a chance to win this
year!
-
Establishing a student board comprised of students from
each of the Universities in the Tampa Bay area. The purpose of the board will be to work with the
Chapter board as liaisons with the student population. Increasing
student involvement and development through mentoring/shadowing programs and general development. Many of these Universities offer the
Fraud/Forensics as a designation now. These are our current and future members and we need to
help them in developing our teams in the fight against fraud!
-
Continuing our scholarship and donation programs. The
board is looking into changing the program slightly, however, we
will continue to support and even exceed the support of prior
years.
We have many more
goals that we will be working towards, however, these are the
key areas. We are still in need of dinner speakers. We need
your feedback on topics that you want to hear about. If you
know any potential speakers, please forward them to Steve Hooper
our Vice-President and he will follow up with them.
Our website has all
of our dates and specifics, please be sure to visit it. Gary
works very hard to keep it up to date with current fraud topics
as well as general Chapter information.
We look forward to
seeing you at the meeting September 11th. Until then
best wishes!
Christine A. Dever,
CPA, CFE
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