# Potential Fraud?



## lawl.shan@gmail.com (Jan 25, 2022)

Hello!
I'm not an auditor, but I think I may have discovered a huge billing issue. 
We have been paid for surgeries over the 2021 year when we shouldn't have. We are starting to see take back requests, but I took it a step further to see how many claims should have a recoopment. It totals about $37.5K. 
I brought this to our office manager's attention, but she doesn't seem like she cares. 
Where I have now discovered this, if no action is taken to notify these payers, wouldn't that be fraud?

Bonus if you can attach links.


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## jkyles@decisionhealth.com (Jan 25, 2022)

Hi there, it is potentially fraud, but a practice that discovers overpayments and doesn't take action could be subject to investigations, accusations of fraud, CIAs and settlements that may be higher than the total overpayment (not to mention the big legal bills) without an admission to or conviction of fraud. The 60-day overpayment rule which was released in 2016 increased the risk of ignoring overpayments. Here's the rule, you can find articles about it online: https://www.govinfo.gov/content/pkg/FR-2016-02-12/pdf/2016-02789.pdf 

One thing to note, practices have 60 days from the time they _complete _an investigation into overpayments to return the money, not 60 days from the first time they discover an overpayment.


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## lawl.shan@gmail.com (Jan 25, 2022)

jkyles@decisionhealth.com said:


> Hi there, it is potentially fraud, but a practice that discovers overpayments and doesn't take action could be subject to investigations, accusations of fraud, CIAs and settlements that may be higher than the total overpayment (not to mention the big legal bills) without an admission to or conviction of fraud. The 60-day overpayment rule which was released in 2016 increased the risk of ignoring overpayments. Here's the rule, you can find articles about it online: https://www.govinfo.gov/content/pkg/FR-2016-02-12/pdf/2016-02789.pdf
> 
> One thing to note, practices have 60 days from the time they _complete _an investigation into overpayments to return the money, not 60 days from the first time they discover an overpayment.


Hey, thank you so much! This is extremely helpful!


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## jkyles@decisionhealth.com (Jan 26, 2022)

Sure and good luck. This sort of event can be an extremely delicate situation, especially if people panic.

P.S. If you haven't already, take some time to review protections for whistleblowers. You probably won't need them but it can't hurt to know in advance.


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## amyjph (Jan 26, 2022)

It is advisable to be tactful and careful when using this word without investigation and confirmation. Just because a payer initiates a take back doesn't necessarily or always mean the billing or coding was incorrect or inappropriate. There should be internal policies and procedures employees were provided regarding compliance upon hire. Further, if you feel a direct manager or supervisor did not take action the next step would be the internal compliance department, director or executive. Companies should have anonymous reporting mechanisms in place such as a compliance or ethics hotline to call without retaliation before jumping to conclusions. Internal compliance departments will conduct an investigation which could involve audits, etc. to determine if the allegations being made are confirmed and next steps.



			https://oig.hhs.gov/documents/provider-compliance-training/945/Compliance101tips508.pdf
		



			https://oig.hhs.gov/compliance/compliance-guidance/
		



			https://oig.hhs.gov/compliance/physician-education/what-to-do-if-you-think-you-have-a-problem/
		



			https://oig.hhs.gov/compliance/physician-education/where-to-go-for-help/
		



			https://www.aapc.com/healthcare-compliance/healthcare-compliance.aspx
		



			https://www.cms.gov/About-CMS/Components/CPI/CPIReportingFraud
		



			https://www.cms.gov/About-CMS/Components/CPI
		



			https://www.cms.gov/newsroom/fact-sheets/medicare-reporting-and-returning-self-identified-overpayments


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## lawl.shan@gmail.com (Jan 27, 2022)

amyjph said:


> It is advisable to be tactful and careful when using this word without investigation and confirmation. Just because a payer initiates a take back doesn't necessarily or always mean the billing or coding was incorrect or inappropriate. There should be internal policies and procedures employees were provided regarding compliance upon hire. Further, if you feel a direct manager or supervisor did not take action the next step would be the internal compliance department, director or executive. Companies should have anonymous reporting mechanisms in place such as a compliance or ethics hotline to call without retaliation before jumping to conclusions. Internal compliance departments will conduct an investigation which could involve audits, etc. to determine if the allegations being made are confirmed and next steps.
> 
> 
> 
> ...


Thank you!
I work for a small business clinic, so implementing policies or recognizing issues like this has been a bit of an issue, after moving from a cooporation. This is extremely helpful and I appreciate it all!!


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## patt1018 (Feb 26, 2022)

If you did not identify the issue at all and your office were audited it would be hard to say fraud was committed because the intent would have to be proven.  Most cases in FWA ends up being a Waste or Abuse situation.   However, since you identified the error if you dont correct it and you get audited then yes, you could be accused of fraud.   Hope this makes sense   Good luck!


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