Medicare Fraud

usalsfyre said:
If you knowingly document SA reason that is not true and consistent with your assessment, it is fraud. Doesn't matter who told you to write what, where.

All we ask of our providers is to document accurately and completely and let someone else worry about getting paid.
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Same here. Write what you see and the let the company figure out the billing/payment on the backend.
 
Vladimir said:
EMT's are liable for what they write. If an EMT beleives there is being fraud committed, report it. You can also anonomously report it, it is your civic duty. Remember, you can be prosecuted if you commit fraud. They will also look at ALL of your patient care reports, and if an employer persuaded you to defraud the United State government, you still defrauded the United States government!

For example when Greybor ambuance was raided in 02, they followed every single ambulance, and went into their offices simultaneously and had everybody at gun point. Even EMT's taking showers were at gun point... And many people (mostly ownership AND management) went to prison.
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I highly doubt anyone was held at gunpoint at any point during that investigation, or most other white collar fraud investigations.
 
Tigger said:
I highly doubt anyone was held at gunpoint at any point during that investigation, or most other white collar fraud investigations.
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Actually, I know a few people that worked there... and one of the guys I was talking to was pulled out of the shower at gun point. It is a federal crime, and they can not let the owners know what is going on... so they can get them by surprise!
 
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OKOKOK... this is how it works...

Their seems to be a little confusion about billing and fraud.

Here is the first thing, a biller can make something up and submit without paperwork! But this is illegal, and they could face serious prison time.
Also, the run sheets you fill out are never sent to the insurance company or medicare (if so rarely)... no one ever sees your runs or narratives, not even chp... It just wouldnt be efficient. Think about it, it wouldnt merit the expense of hiring all the auditors necessary!

An E.M.T. commits fraud when they lie on these forms because these forms are audited by medicare if their is ever a problem... and if these forms show the E.M.T. was complicit with the fraud then this is a problem. Because, ultimately you could be made an example out of, even though they usually go only after the big fish.

When fraud is detected or investigated, they will audit the patient care reports, and you dont want to make the FBI's job harder, do you?

Also, an ambulance can transport anybody they wish, even if they do not need an ambulance (and yes, no matter if you do not get paid, legally you must still fill out a patient care report)... but that doesnt mean that they will get reimbursed by the insurance company. Some may attempt reimbursement, and they may lie and cheat, and attempt to get you to lie and cheat... but if i were you, i'd keep my nose clean. It can be potentially sooo much worse for you if you do not!
 
Vladimir said:
Their seems to be a little confusion about billing and fraud.

Here is the first thing, a biller can make something up and submit without paperwork! But this is illegal, and they could face serious prison time.
Also, the run sheets you fill out are never sent to the insurance company or medicare (if so rarely)... no one ever sees your runs or narratives, not even chp... It just wouldnt be efficient. Think about it, it wouldnt merit the expense of hiring all the auditors necessary!
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This is a bit oversimplified.

As I understand, a form which is generated based on your run report is sent for reimbursement.

Upon receipt, one of 3 actions is generated.

1. denial
2. acceptance and immediate pay
3. request for more information and up to 90 days to pay(audit)

The real danger is number 2.

Because if you falsified something to make it go through, it is your biggest chance of being caught.

I also understand that one of the way anyone decides to have a closer look at you is by the percentage of immediately accepted payouts to denials and audits compared to other similar companies.

If you are audited and then denied that is not a crime.

There are legitimate uses of "magic words" to expedite billing. The problem comes when you are using these words when they shouldn't be. (like on all of your documents regardless of pt. condition)

I only ever met one guy who admitted working for the FBI, on career day in highschool, they are a rather sharp bunch and generally do not target the peons.

Getting rounded up in a bust and released isn't the end of the world. But I bet it makes for a really scary and bad day.
 
I was askd at my old company to change a run sheet from standing pt to sitting patient. To put that we had to GS the pt onto the gurney which was totally false. PT was a medicare pt I refused and quit. Found a legit large company and havnt lookd back! my supervisors words "bro if we put that the pt was standing and got on the gurney, we wont get paid for it." This was at a private residence so it landed on me. They use to pick up out of LA county with out LACO stickers and still do . Simple advise leave and dont ever lie. These companys exsist all over LA.
 
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Hmmmm, the use of the word "bro"......was this company out of Glendale?
 
Veneficus... That probably would ruin anybody's day! lol
But yeah, that's close to being it... but billing is relatively easy, everything is automated, billers want to make it sound like it is the hardest thing in the world, but it really is SIMPLE!!! A lot of billers make a percentage of the gross! so sometimes 5-10%!!!

btw, You dont even use words! its all codes! You cant use "magic words", it all boils down to using you as a scapegoat! lmao...
if they can prove you incompetently used a "magic word" to fill out the run sheets, then when they get audited, there was no malintent! they will still have to pay back money if they get caught, but they wont get into trouble for fraud... one of the components for fraud is intention.
 
by the way... do you even know how many companies have been investigated or shut down for all sorts of things in the last year or so??? A LOT!!!
I can think of 10 in the Los Angeles area, all within a 20 mile radius!!!

Beleive me, regular employees do not find out a lot of stuff that goes on in the industry... Just remember, YOU ARE NOT JUST A FLESH HAULER! You are a medical professional who has the lives of real people in your hands, that depend on your decernment, and the public at large looks up at you, and this gives you a degree of authority... God help the victim of a TC that crosses paths with an EMT that views himself as a "Flesh Hauler"!!!
 
Status Update.....We're almost 14....10-9?
 
You've moved on to greener pastures?
 
I've been there for 6 months :(
 
Vladimir said:
Veneficus... That probably would ruin anybody's day! lol
But yeah, that's close to being it... but billing is relatively easy, everything is automated, billers want to make it sound like it is the hardest thing in the world, but it really is SIMPLE!!! A lot of billers make a percentage of the gross! so sometimes 5-10%!!!

btw, You dont even use words! its all codes! You cant use "magic words", it all boils down to using you as a scapegoat! lmao...
if they can prove you incompetently used a "magic word" to fill out the run sheets, then when they get audited, there was no malintent! they will still have to pay back money if they get caught, but they wont get into trouble for fraud... one of the components for fraud is intention.
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Figuring out how to make stuff up to get paid and not get audited or busted is hard work :)
 
Vladimir said:
by the way... do you even know how many companies have been investigated or shut down for all sorts of things in the last year or so??? A LOT!!!
I can think of 10 in the Los Angeles area, all within a 20 mile radius!!!

Beleive me, regular employees do not find out a lot of stuff that goes on in the industry... Just remember, YOU ARE NOT JUST A FLESH HAULER! You are a medical professional who has the lives of real people in your hands, that depend on your decernment, and the public at large looks up at you, and this gives you a degree of authority... God help the victim of a TC that crosses paths with an EMT that views himself as a "Flesh Hauler"!!!
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I don't haul flesh :)

Thanks for the insights. Inside information is always appreciated.

If I haven't mentioned before, I suspect much of the medicare/medicade fraud going on is organized, not random companies.

Either there is an expert with inside knowledge trying to stay just legal in order to make some money. (As we saw in Florida several times after they were caught)

or an actual organized crime link, that was playing at odd of prior lax enforcement and basically taking what they could get before being caught.

As for increased enforcement, I think it is a political game. As I mentioned, the amount of medicare fraud while seemingly like a lot, in the grand scheme probaly isn't much.

But somebody needs to be able to say they are "doing something" to reduce medicare costs and who doesn't rally around "cracking down on the bad guys?"

Sounds a lot better than "slashing benefits" on the TV.
 
You're right, but It is no political game... because the government hates those who conspire against it too much!:ph34r:
 
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