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Department of Health Care Services Audits & Investigations Medical Review Branch Agenda Item 5 BRD 5-1
Department of Health Care Services
Audits & InvestigationsMedical Review Branch
Agenda Item 5
BRD 5-1
2
Healthcare Expenditures Industrialized Nations : % 2011 GDP
Canada10.91
USA17.98
Brazil8.90
Israel7.73
Australia9.03
Japan9.27
EuropeUK 9.32France 11.63Germany 11.06Sweden 9.36Switzerland 10.86
US GDP 2011 : $14 .9 trillionHealth care spending: $2.8 trillion
World Health OrganizationTotal expenditure on health as a % of Gross Domestic Product, 2011
China5.15
South Africa8.66
Fraud, Waste & Abuse19%
Thomson Reuters, 2009
Agenda Item 5
BRD 5-2
Error
Incorrect Coding
Waste
Medically Unnecessary
Service
Abuse
Improper billing
practice
Fraud
Billing for unnecessary Services or Supplies not
Provided
Intentional Deception
Bending the RulesInefficienciesMistakes
Agenda Item 5
BRD 5-3
$70 billion (2014)1 in 5 people covered
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BRD 5-4
5
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A con artist is a professional
A con artist needs a conduit
A con artist needs a victim to take the fall
A con artist doesn’t care about the harm
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Focus on medicine
Not taught about business (e.g. Don’t sign a blank contract!!!)
The National Provider Identifier is like a credit card without a limit
Agenda Item 5
BRD 5-10
Deficit Reduction Act of 2005
Program integrity is the practical concept that programs should be organizationally and structurally sound
Health care – programs efficient, effective, ethical Corollary: prevent fraud, waste & abuse
Agenda Item 5
BRD 5-11
Medical and Audit staff
Pre-Enrollment Reviews Utilization Controls Sanctions Referrals Studies Compliance Audits Outreach
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BRD 5-12
Medical Board
Pharmacy Board
Centers for Medicare and Medicaid
Department of Justice
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BRD 5-13
Prevention Disclosure Knowledge is Power Stop unlicensed practice
Affordable, quality care
Best use of dollars
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Identity Theft versus Identity Lease
Avoid Patient Harm
Close the Knowledge Gap
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BRD 5-18
Professional Societies California Medical Association Webinars Partner with Centers for Medicare & Medicaid Residency Programs Journal articles Education materials
Patients Providers
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Need to Reach a Wider Audience
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3 one hour Interactive Webinars
Developed with Xerox (fiscal intermediary)
Free
Goal – Free Continuing Medical Education
Subject Matter Experts
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BRD 5-21
Module I Impact of fraud, waste & abuse
Module II Prescribing & Referring
Module III Documentation & Internal Controls
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BRD 5-22
Timeliness
Impact of prescribing
Videos/input from other experts
Welcome Medical Board support
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BRD 5-23
Attitudes
Education
Benefit for the greater good
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