Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Rules Based Healthcare Continuum (R-HCC)

R-HCC Application

The rules, in this context, are straightforward. Dr. Traveler cannot provide false pretense for free health screenings and enter into senior citizen complexes and nursing home facilities to “shop” for patients or steal their medical identities. Dr. Traveler cannot submit claims for services rendered that he did not provide. Dr. Traveler cannot charge for services by his unlicensed staff. Where can we find these rules? The first place is on the back of the claim form. Many are used to only looking at the front of the claim form, as they are focused on entering the required data for claims submission. However, do not focus only on the back of the Centers for Medicare and Medicaid Services (CMS)-1500 professional claim form as shown in Exhibit 8.2.*

Exhibit 8.2 CMS Claim*

BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading Information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLY

MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided In Blocks 1 through 12 is true, accurate and ...