Posted and filed under Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Training and education.  We in the fraud, waste and abuse world just can’t get enough of it.  I recently took the Certified Fraud Examiner’s certification test (and thankfully passed).  I have continuing education credits each year to seek out, and I am excited to do some extra learning.  This past week, I conducted numerous educational trainings to law firms and the coding community.  It is something that I really enjoy doing.  It is a combination of the presentation, having to be quick witted to keep the audience engaged, and the questions that come from the groups where there is no opportunity to prepare for what is asked.

I found the coder training sessions to be the most interesting to me (not to take away from the legal community, who always ask very detailed and introspective questions).  Coders are black and white people by nature; it was, or it was not documented and coded appropriately.  Coders get an abundance of training in a lot of areas involving their profession, but they get very little education and training in fraud, waste and abuse.  Most coders with whom I have met, are intuitive and know their craft.  When I conduct trainings for this group, I am almost always amazed how much of an eye opener it is for them to learn about the various fraud, waste and abuse schemes that are out there.

In my most recent training session, I discussed home visit fraud schemes and podiatry fraud.  After a review of the CPT codes used for such services, I discussed schemes such as “gang visits” for providers who line patients up in the community rooms of senior citizen buildings, to instances where home health agencies submit claims for reimbursement for more hours of service than were provided to the beneficiary.  In both of those examples, coders were astonished to learn that there were/are actual fraud schemes that are perpetuated by unscrupulous providers in the healthcare community.

When I discussed podiatry fraud, there were two coders who do nothing but podiatry coding and billing.  As we discussed some of the schemes with respect to circumventing the edits in place to prevent some of the fraud in the specialty, the coders began to identify instances where they were put in the terrible position of having to potentially code services that they felt were questionable.  Prior to our discussion, the “light” never got flipped on to understand how some of the fraud schemes out there were potentially being facilitated by their submission of the claim.

I liken this to the fact that most healthcare providers receive little, if any, training on fraud, waste and abuse.  It has caused me to ponder that if the healthcare community, and particularly billers and coders, were more educated on fraud, waste and abuse, would they all be better at being gatekeepers of what we have all come to consider a terribly broken system of how healthcare insurance operates?  I have been asked to speak at a number of coder meetings and training sessions recently.  When asked, I am told frequently that it is an area of great interest to them.  This is because of their inherent interest in learning about fraud, waste and abuse, as well as an interest in auditing and payment integrity.  Either way, it excites me to be able to share my area of interest, while at the same time potentially creating a layer of compliance that is clearly needed.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.