Posted and filed under Fraud, FWA.

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.

Recently, I was speaking with a client regarding Chronic Care Management (CCM), and the ability to incorporate this as a “business line” in addition to medical care and treatment. This was an entirely new area for me, so it required me to take a deeper dive into what CCM is. Without going too deep into it, after doing some reading and seeing what this client wanted to do, I of course began to think to myself “no, no, and more no.” As I often say to Jeanmarie Loria, the CEO of Advize Health, from a compliance perspective “in a world of no, I am more no.”

The client, a medical provider, wanted to enter into an agreement with an entity that oversees all aspects of CCM, exclusive of the medical care. The provider claimed that since they have a relationship with the patient, they can identify those patients who need CCM related services. By way of background, in 2015, Medicare began paying for CCM related services, and includes language that allows for the CCM to be rendered via the “incident to” provision (which is an entirely different area of FWA concern-not necessarily relating to CCM specifically). According to this client, the CCM service is not a Medicare provider. The billing would be via the provider NPI, and the fees associated with the provision of the CCM services would be paid to the CCM service as a pass-through, meaning, the client would not take any of the reimbursement money.

Of course, the first thing that came to mind was why would the client engage in such a relationship? I am actually still not sure, since the volume of patients that need CCM by the client is potentially relatively small in comparison to the overall patient population. There are a host of other aspects of the relationship that made me raise an eyebrow. Suffice to say, that even if this was an entirely legal arrangement, it would be something that would not generally pass my FWA “stink test.” In fact, in discussing what some of the services the patient would be receiving as part of the CCM, the client explained that the patient would be obtaining meals on wheels, fresh produce coupons, etc. In my mind, things that were otherwise available to be coordinated right from the client, or through community services.

When I began to hear the list of “things,” it reminded me of the genetic testing fraud case I worked, where the sales representative from the testing lab would use his bogus not for profit to solicit patients for the swab, as part of his broader “discussion” of federal, state and local programs available to the senior population he was in front of for his presentation. Anyone that reads my blogs on a regular basis, has spoken with me, or knows me, is aware that I have a particular disdain for those who perpetuate their fraud through the deceit of the Medicare population.

They are not generally technologically savvy; many are lonely for discussion and are at risk for the greatest level of social engineering possible. Although I do not believe that CCM related services and care fall into that category (and to the contrary, can be a great service that is essential to activities of daily living for the targeted population), anyone in the FWA world can surely see that there is a huge area of opportunity here for fraud. In fact, as a result of speaking with this client, we at Advize are going to be taking a deeper dive into the data we have for our payer clients, as well as discussing both opportunities and pitfalls with our provider clients. 

After a long OIG career as a Special Agent, I was never surprised when I came across a new fraud scheme, money-making opportunity, rule, or regulation where I shook my head and thought it was just a matter of time. Now, more than ever in my consulting retirement world, I see it from different perspectives. As I say to people when seeing a fraud scheme that is similar to others I have seen, “the circus may have moved, but the clowns have remained to manage the tent.”

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.