From: mha23x@gmail.com   
      
   Mental Health Fraud Exacts High Human and Financial Costs   
      
   Andria Jacobs, RN, MS, CEN, CPHQ   
   Ms Jacobs is the chief operating officer for PCG Software and has more than 25   
   years’ experience in the healthcare industry, encompassing both   
   administrative and clinical arenas. Prior to joining PCG, Ms Jacobs was the   
   administrative director, medical    
   management for VertiHealth Administrators. Previously, she was an independent   
   consultant in ambulatory care and practice management, where her clients have   
   included hospitals, physician groups, and the University of California, Los   
   Angeles.   
   Friday, March 11, 2016   
       
   The United States loses approximately $100 billion to healthcare fraud   
   annually. Up to $20 billion dollars are due to fraudulent practices in the   
   mental health sector. One of the largest healthcare fraud cases in US history   
   occurred in behavioral health -   
   - one of healthcare’s smallest sectors.   
   Mental Health Fraud Exacts High Human and Financial Costs   
      
   The United States loses approximately $100 billion each year to healthcare   
   fraud. Up to $20 billion dollars are due to fraudulent practices in the mental   
   health sector. One of the largest healthcare fraud cases in US history   
   occurred in behavioral health-   
   -one of healthcare’s smallest sectors.   
      
   Like  home care , this arena requires the utmost in integrity because crime in   
   the mental health sector hurts healthcare’s most vulnerable, underserved and   
   disenfranchised patient populations, while escalating costs.   
      
   The HHS Office of Inspector General and partners are making some progress   
   cracking down, especially where patients suffer harm. Some of the worst cases,   
   however, continue to occur in partial hospitalization programs (PHP),   
   involving intense outpatient    
   psychiatric care in ambulatory departments of hospitals or Community Mental   
   Health Centers (CMHC). Some CMHCs bill for mental health services but instead   
   provide at best recreational adult day care.   
      
   Consider a couple of illustrative cases. A CMHC operator in Louisiana and a   
   CMHC patient recruiter in Texas were imprisoned for their roles in a   
   multimillion-dollar Medicare fraud scheme. In Baton Rouge the recruiter   
   invited beneficiaries to attend PHP    
   programs knowing the patients didn’t need psychotherapy and kept them at   
   facilities as long as possible without triggering Medicare audits. Staff also   
   altered records to make it look as if patients received therapy when they   
   didn’t.   
      
   In Houston the recruiter invited beneficiaries to attend a PHP in exchange for   
   cash payments. The 2 fraudsters received prison sentences of 90 months and 60   
   months, respectively. Three companies involved in the case collectively filed   
   more than $258    
   million in inappropriate Medicare claims. Seventeen people were convicted,   
   including the psychiatrist co-owner of the Louisiana CMHC and the Houston   
   facility, who was sent to prison.   
      
   In another case in Houston, 3 individuals earned 12, 20 and 45 years in prison   
   and were made to pay more than $100 million in restitution for their roles in   
   a $158-million PHP scam. Beneficiaries watched television all day, patients   
   with dementia couldn†  
   ™t understand or were not capable of participating in therapy they allegedly   
   received, and others never were admitted to hospital. The scheme included   
   kickbacks to recruiters and group home operators for bringing ineligible   
   Medicare beneficiaries to the    
   organization.   
      
   As mental health services expand in the wake of the Affordable Care Act,   
   rooting out fraud, waste and abuse in this arena becomes even more critical.   
   Even though we’ve improved coverage, the actual provision of services   
   remains difficult to measure.    
   Confidentiality issues and the social stigma and secrecy that surround mental   
   health further discourage patients and families from speaking up and   
   complaining.   
      
   As I said in my article on waiving co-pays and deductibles, there is no free   
   lunch. It is important for organizations to employ a variety of techniques to   
   stamp out fraud, including checking websites and social media for offers of   
   â€œfreeâ€� mental    
   health services and to pay attention to any patient and family complaints and   
   act promptly to resolve them. It is also vital to periodically visit   
   facilities to make sure they meet quality standards and qualified staff are   
   providing the therapeutic    
   services they advertise.   
      
   In reimbursement, the main question to ask is: does the patient record reflect   
   the patient’s level of care being billed? Billing for more claims per day   
   than there are hours in the day should be a dead giveaway for fraud. But like   
   everything, it takes    
   paying attention and acting to keep on top of wrongdoing. After all, how many   
   intense 90-minute therapy sessions can a psychotherapist reasonably administer   
   in a work day?   
      
   Documentation is critical for behavioral health practitioners. To comply with   
   federal and state laws, practitioners must maintain the records necessary to   
   â€œfully disclose the extent of the services,â€� care and supplies furnished   
   to beneficiaries, as    
   well as support claims billed. Additionally, proper documentation can help   
   protect a behavioral health practitioner from challenges to furnished   
   treatment, and civil, criminal and administrative penalties and litigation.   
   Services must meet specific    
   requirements for reimbursement.  That means services must meet your state’s   
   program rules, reflect medical necessity, and match active treatment,   
   including patient face-to-face time, and be coded correctly for billing   
   purposes.   
      
   Behavioral health practitioners should never bill “chance, momentary social   
   encounters between a therapist and a patientâ€� as valid therapeutic sessions,   
   never invoice undocumented services and never charge for services coded at a   
   high level than    
   those furnished.   
      
   I began this article sharing the financial costs of mental health fraud, but   
   let us not forget fraud is anything but victimless. Not only does fraud in   
   taxpayer-funded government programs affect all of us as US taxpayers, but it   
   cruelly denies    
   individuals basic human rights, especially those struggling with severe mental   
   illness.     
       
      
      
   See more at: http://www.ajmc.com/contributor/andria-jacobs-rn-ms   
   cen-cphq/2016/03/mental-health-fraud-exacts-high-human-and-finan   
   ial-costs#sthash.6gDmOLaD.dpuf   
      
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