Fraud, Waste and Abuse…Oh My!

Dr. R. A. Foxworth, FICC, MCS-P

In today’s era of regulatory hyper-focus, just about every chiropractor is painfully familiar with the phrase “Fraud, Waste, and Abuse.” In fact, it’s even got its own acronym: FWA. But a surprising number of doctors only have a partial grasp of the difference between these terms. And an alarming number don’t know that what their practice might be doing puts them at risk of coming under FWA investigation or audit by the OIG, CMS, or a private insurer.

It’s never been more important to reduce your risk of non-compliance and its costly consequences. Your peace of mind, not to mention your practice, are at stake.

Fraud is defined by action plus intention. For example, in order to qualify as potential fraud, the following conditions much be present:

• There must be a cause of deception (you did something bad).
• The act or acts must show an intentional misrepresentation of fact (you knew you were doing something bad).
• The provider stands to gain financially from the deception and misrepresentation (you’re going to make money from being bad).

Abuse, on the other hand, could happen under the same instances as fraud, but the significant difference is that there is no knowledge of, or intent to, defraud. In other words, a provider could be operating outside the lines of “accepted sound clinical, business, or fiscal practice,” but is simply ignorant or unaware of their mistakes. Examples might include excessive or unnecessary care, improper business practices, poor clinical documentation, and coding and billing mistakes. (Source: American Chiropractic Association, https://www.acatoday.org/Practice-Resources/Position-Statements/Fraud-Waste-and-Abuse)

Waste is listed as a separate term, but it’s really Abuse with the added insult of your having “wasted” the resources of the OIG/CMS by your actions. This term is important because it represents the displeasure of the government. They mean: stop being careless and wasting our money.

You could get caught up in an audit any number of ways. Both governmental agencies and private insurers use algorithms and other methods to detect aberrant patterns of coding and billing. If you’re an outlier, you raise both eyebrows and red flags. You could also be reported by a disgruntled employee, a competitor, or even an angry patient.

If you don’t have an ACA-mandated compliance program within your policies and procedures manual, and proof that you not only keep it updated but train your staff regularly, you’re putting your practice at significant risk.

As a ChiroHealthUSA provider, you are able to offer safe and legal network discounts to your patients helping you avoid some of the FWA traps that other doctors fall into. ChiroHealthUSA also provides a wealth of information and resources to help you stay compliant and protect yourself as well as your practice. Bookmark our weekly webinar page to see how our various practice consultants and chiropractic experts are keeping our members abreast of the latest information you should know.