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   Kusserow's Corner:    
      
   Mental Health Ranks High on Fraud Scale   
      
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   Occasionally, I take time to bring attention to enforcement actions in various   
   health care sectors. Some recent actions drew my attention back to a special   
   enforcement problem that stretches back decades to my days as Inspector   
   General--mental health.    
   Billions of dollars are spent to address the ever-increasing demand to treat   
   mental stress and illness. The primary purpose of mental health treatment must   
   be the therapeutic care and treatment of individuals who are suffering   
   emotional disturbance.    
   Proper treatment therefore demands the highest level of trustworthiness and   
   integrity in the practitioner, who treats some of the most vulnerable   
   patients. Two sources of funding are Medicaid and state general fund dollars,   
   which on average fund 90    
   percent of the system. However, about 10 percent is funded by Medicare,   
   federal mental health services block grant funds, and county or municipal   
   funds. As with other areas of health care, a significant portion of these   
   funds are diverted to fraud within    
   the mental health industry. Many health care fraud investigators believe   
   mental health caregivers, such as psychiatrists and psychologists, have the   
   worst fraud record of all medical disciplines. Much of that is attributable to   
   prescriptions for narcotic    
   drugs and taking advantage of some of the vulnerable individuals who suffer   
   from mental illness or Alzheimer's disease.   
      
   Last year the HHS Office of Inspector General (OIG) issued a report focusing   
   on one aspect of the problem: detecting and deferring mental health fraud in   
   community mental health centers (CMHCs). CMHCs provide partial hospitalization   
   program services to    
   approximately 25,000 Medicare beneficiaries. The OIG report cited numerous   
   arrests by Medicare Fraud Strike Forces evidencing significant levels of CMHC   
   fraud. The OIG review found that one of nine MACs reviewed performed   
   activities to detect and deter    
   CMHC fraud, and most of these were part of a CMS-led special project.   
   Activities to detect and deter CMHC fraud varied substantially among ZPICs   
   with many performing minimal activities to detect and deter fraudulent CMHC   
   billing. The report provided a    
   number of recommendations to increase control and enforcement in this arena.   
   However, this is only one area of Medicare that addresses mental health. Other   
   areas are equally prone to fraud and abuse.   
      
   The latest in the Medicare enforcement arena comes from Louisiana where the   
   owner of three mental health centers was sentenced to pay $43.5 million in   
   restitution and serve 8-and-one-half years in federal prison for a Medicare   
   fraud scheme. A    
   psychiatrist, who served as medical director and co-owner, was sentenced to 86   
   months in prison for his role in admitting mentally ill patients to the   
   facilities, some of whom were inappropriate for partial hospitalization, and   
   then re-certifying the    
   patients' appropriateness for the program in an effort to continue to bill   
   Medicare for services. These were among 17 people who worked at the three   
   facilities in a variety of roles who also been charged in the fraudulent   
   operation that stretched seven    
   years and involved over a quarter-billion dollars in Medicare fraud. They   
   included therapists, marketers, administrators, owners, and the medical   
   director. The companies billed Medicare for unnecessary or never provided   
   partial hospitalization program    
   services for the mentally ill. The companies, collectively, submitted more   
   than one-quarter-billion dollars in claims to Medicare during this period. The   
   scheme also involved falsifying records indicating patients had treatment they   
   never received and    
   paying recruiters to, in turn, pay patients to attend hospitalization programs   
   at the facility in order to make Medicare claims.   
      
   The fraud problem is actually larger and more pervasive in the Medicaid   
   program, which provides significantly more funding to this area. For example,   
   last year New Mexico was in the midst of a sweeping criminal investigation   
   into 15 of its largest mental    
   health providers, suspected of defrauding Medicaid of $36 million over three   
   years.   
      
   Examples of Fraud in the Mental Health Sector   
      
   Altering and/or falsifying records to match services billed   
   Billing for services not actually performed   
   Errors and falsification of patient charts   
   Fabricating patient files   
   Paying kickbacks paid to recruiters to find beneficiaries   
   Lack of a referral form from an approved provider source   
   Lack of documentation for service provided   
   Service notes lack specific treatment goal   
   Billing for service not covered by Medicaid as a covered service   
   Billing for a more expensive service than was actually rendered   
   Prescribing category narcotic drugs to addicts or for selling on the street   
   Changing the billed date of service to match client dates of eligibility   
   Deliberately applying for duplicate reimbursement in order to get paid twice   
   Inappropriate billing that results in a loss to the Medicaid program   
   Providing services which are not necessary   
   Billing for services performed by unqualified persons   
   Richard P. Kusserow served as DHHS Inspector General for 11 years. He   
   currently is CEO of Strategic Management Services, LLC (SM), a firm that has   
   assisted more than 3,000 organizations and entities with compliance related   
   matters. The SM sister company,    
   CRC, provides a wide range of compliance tools including sanction-screening.   
      
   Connect with Richard Kusserow on Google+ or LinkedIn.   
      
   Subscribe to the Kusserow's Corner Newsletter   
      
   http://health.wolterskluwerlb.com/2014/09/kusserows-corner-menta   
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