2015 User Conference

Forensic AccountingApril 24, 2015

Presented by:

Christopher Becker Aimee HeckmanDirector- RCM Manager-OP15 RCM

PM Session

2015 Office Practicum User Conference

Forensic Accounting

DefinitionsFraudA false representation of a matter of fact

LarcenyThe act of dishonestly withholding assets for the purpose of

conversion(theft) of such assets, by one or more persons to whom the

assets wereentrusted, either to be held or to be used for specific

purposes...alsoknown as embezzlement.

LazinessAverse or disinclined to work, activity, or exertion; indolent

2015 Office Practicum User Conference

Forensic Accounting

Fraud in Medical Offices 1.Upcoding2.Unbundling3.Misrepresenting information

a. Datesb. Diagnosisc. Services (CPT codes)d. Patient Identitye. Services not performedf. Provider of Service

4.Differing Fee Schedules

Statistics:

The average organization loses 5 percent of total annual revenue to fraud and abuse by its own employees. (MGMA 2011)

2015 Office Practicum User Conference

Forensic Accounting

Larceny and Laziness (L&L)1.Payments in Cash2.Credit Card Theft3.Refund Checks to Friends4.Check Theft5.Increasing A/R6.Receipts that don’t match up to encounters7.Patient complaints (“I paid that copay”)8.Diminishing cash flow when receipts appear normal9.Billing Adjustments

a. Insurance balance on under-paid/rejected claimsb. Insurance balance to hide timely filing errorsc. Insurance and patient balance to make AR look goodd. ….the list goes on

2015 Office Practicum User Conference

Forensic Accounting

REMEDIESFraud1.Understand Coding rules. OP suggests E/M codes, make sure everything is documented in the note. The AAP has an excellent book published yearly on physician coding.2.Fully understand the rules of your state and medical board involving mid-level providers and billing for their services.3.Dates, Dx, CPTs and patients should never be changed to favor billing. 4.If a claim for services has been paid and discovered the service was not performed, immediately refund the payment to the payer.5.The person charting is always the provider of service, never allow someone to chart under your name.6.Medicaid, Medicare (not huge in peds), and most plans forbid different fee schedules. Included in this area are discounts and waived copays. VFC and capitated plans are exempted from this rule.7.Peer review of charts on a regular basis is recommended in order to catch these issues and remedy them ahead of a plan chart audit.

2015 Office Practicum User Conference

Forensic Accounting

REMEDIESLarceny1.OVERSIGHT

a. Every practice should conform to “GAAP” b. Set security privileges in OP (OP14 has expanded on these) that

are appropriate for the employee’s position.c. Be certain the daysheet deposit numbers for each payment

method are the same for bank deposit.d. Never store credit card numbers in OP or anywhere else in the

practice. If using a printer, limit who has access to the reports. e. Request cancelled checks from the bank, check endorsements.f. Require use of strong passwords that change often. Never give

your password to anyone else.2.FORENSIC REPORTS

a. Review the Daysheet report daily. Look for oddities and follow up with the staff, which makes them aware that there is oversight.

b. Reimbursement Analysis Report- A great report that can be set up to look for fully paid claims with questionable adjustments.

2015 Office Practicum User Conference

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2015 Office Practicum User Conference

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