Prevention of Fraud and Abuse

MHCA is committed to ensuring that its operations include appropriate measures to identify and prevent fraud, waste and abuse (FWA) within the network, and we rely on our providers to help us in these efforts.  To that end, we would like to provide the following examples of FWA that we may encounter in our network:

 

  • Waste generally refers to misuse of resources. An example of this is scheduling patients more often than is medically necessary, or performing unnecessary laboratory tests.

 

  • Abuse is defined as incidents or practices that either directly or indirectly results in unnecessary costs. In our network, an example of abuse is billing for a higher reimbursing code that is not reflective of the service that was actually performed.

 

  • Fraud is defined as an intentional misrepresentation or deception, to obtain money or some other personal benefit by deliberate deception. Examples of health care fraud include knowingly billing for services that were not rendered, or intentional misrepresentation of services provided.

 

DIAGNOSTIC AND CODING RESOURCES TO HELP PREVENT IMPROPER BILLING

 

Perhaps the simplest and most effective step a provider can take to prevent FWA in their own practice is to ensure, before submitting a claim, that the clinical documentation accurately reflects the service provided, and that the billing for each service is accurate.  To help you determine the appropriate diagnostic and service codes, we recommend you have the following resources available:

 

  • DSM 5 – describes the diagnostic criteria
  • ICD 10 – based on the DSM 5 criteria, use this resource to determine the most specific diagnostic code to submit on your claim
  • CPT – use this resource to determine the appropriate procedure code for the service you rendered

 

Under no circumstances should a claim be submitted for payment before the patient encounter is documented in the medical record.

 

ADDITIONAL RESOURCES TO HELP YOU PREVENT POTENTIAL FWA IN YOUR PRACTICE

 

The MHCA Participating Provider and Facility Manual is accessible on the “For Providers” tab of this website.  It contains valuable information regarding clinical documentation requirements and claims submission.  All network providers are expected to adhere to these guidelines when documenting services that are billed to MHCA.

 

www.cms.gov – The Centers for Medicare and Medicaid Services website includes a wealth of information that is relevant to your practice, even if you do not accept Medicare, or you are not eligible to treat Blue Advantage members.  For example, under the “Outreach and Education” tab you will find links to Medicare Learning Network (MLN) articles on topics such as Evaluation and Management Services, and Complying with Medicare Signature Requirements.  We recommend that all physicians search the CMS website for a brief video entitled, “CMS Provider Minute: Psychiatry and Psychotherapy.”  This is an excellent description of how you must document add-on psychotherapy services in order to be in compliance with the coding guidelines.

 

www.oig.hhs.gov – The Office of Inspector General maintains the list of individuals and entities that are excluded from participation in Federal health care programs, and you can find a link to the Exclusions Database on the OIG home page.  Also on the OIG website we encourage you to look at the Compliance 101 and Provider Education link, for voluntary compliance program guidance for individual and small group physician practices.

 

www.hhs.gov – On the Health and Human Services website you will find information on topics such as HIPAA privacy and security rules, breach notification rules (including reporting breaches to the HHS Secretary), and cloud computing.

 

www.bcbsal.org – For providers in the EPS and Blue Choice networks, we advise that you review the Blue Cross and Blue Shield of Alabama Provider Manual, which can be found in the Forms and Manuals section of their website.

 

PROVIDER RESPONSIBILITY

It is the responsibility of each provider to be familiar with the applicable laws and regulations pertaining to documentation, coding and billing.  MHCA offers virtual and live training events throughout the year to provide education on relevant topics; however, it is important that you take the necessary steps to educate yourself on these issues, and we strongly encourage you to look for additional resources (i.e. newsletters, CE events, legal advice) that will provide you with the information you need to ensure your practice is in compliance with all applicable laws and regulations.

 

HOW TO REPORT FWA

MHCA employees, network providers and members of the public have a number of options for reporting suspected cases of FWA.  Concerns may be reported by any of the following methods:

 

  • Calling the Compliance Officer directly at (205) 968-8422
  • Calling the toll free MHCA Compliance Hotline at (844) 814-4025
  • Writing to the Compliance Officer at the following address:

MHCA
Compliance Officer
956 Montclair Rd., Suite 200
Birmingham, AL 35213

Reports may be made anonymously, and to the extent feasible, the anonymity and confidentiality of any individual who makes such a report shall be maintained.

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