Fraud and abuse are definitely buzzwords right now when it comes to the EMS industry. In our last few blogs we’ve discussed the importance of proper documentation and how your reports can help your department get reimbursements from Medicare. While this remains true, it’s important not to get so caught up in getting reimbursed that you move into the territory of exaggerating or even falsifying your report to ensure reimbursement – this would qualify as fraud and is not something we at AccuMed advocate for.

So, what are fraud and abuse, and how do they differ? Abuse is defined in the Medicare rules as: “Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicare program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicare program.” The major difference between the two is that abuse can be done unintentionally, whereas fraud involves, “An intentional deception or misrepresentation.”

Unfortunately, it’s easier to enter into fraud or abuse territory than one might think. A few examples of things that qualify: a crew member telling a patient they won’t get a bill, documenting a patient couldn’t sit up or walk, when a crew member never assessed the patient for this, documenting an EKG was done, when it wasn’t or signing in place of the patient or facility staff member because the crew forgot to get a signature. These are all things that may not seem like a big deal initially, but can cause major consequences for you and your department in the future.

Here are a few things to ask yourself:

  • Does your department or agency have a compliance plan in place?
  • Does your department or agency have a compliance officer?
  • Are you aware of the steps your biller has in place?
  • Are you only documenting what actually happened?
  • Is your current biller making sure you’re participating in annual security risk assessments?
  • Are you keeping up to date on industry rules or regulation changes?

While this list is definitely not all encompassing, it’s a good starting point to try to figure out where you are in terms of fraud or abuse. If you’d like more detail on this topic, ask your biller or look at these additional resources from CMS and the OIG.

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