Fraud/Abuse

Question 1

fraud

Answer 1

intentional deception or intentional misrepresentation that a provider makes to gain a benefit for which that provider is not entitled

Question 2

abuse

Answer 2

payment for items or services when there is no legal entitlement to that payment, and the provider has NOT knowingly and/or intentionally misrepresented facts to obtain payment

Question 3

waste

Answer 3

overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system. not criminally negligent actions, but payment errors or misuse of resources

Question 4

false claims act

Answer 4

-imposes liability on any person who submits a claim to CMS that he/she knows is false
-protects federal gov from being overcharged or sold substandard stuff

Question 5

knowing standard

Answer 5

acting in deliberate ignorance or reckless disregard of the truth
-examples:
knowingly billing for services not provided
knowingly altering claims to recieve higher payment
falsifying documentation

Question 6

safe harbors

Answer 6

-not subject to statue bc they are unliekly to result in fraud or abuse

Question 7

anti kickback statute

Answer 7

criminal offense to knowingly and willfully offer, pay, solicit or recieve bribes or kickbacks to induce or rewards referrals in order to induce busines reimbursavle by a federeal health care porgram

Question 8

facts about kickbacks

Answer 8

distort medical decision making
-can result in:
overutilization, increased costs, unfair competition

Question 9

kickback examples

Answer 9

cash payments
trips/fancy diners

Question 10

when is rental of office space from pysicain ok?

Answer 10

-space is fair market value
-rent is fixed
-amount of rent does NOT vary basewd on value or value of refferals

Question 11

physiican self referral law/stark

Answer 11

-physiican referring a pt to facility in which he/she has financial interest
-conflict of interest
-encouirages overutilization of ervices
-creates captive referral system and limits competition

Question 12

physiican self referral law/stark

Answer 12

-physiican referring a pt to facility in which he/she has financial interest
-conflict of interest
-encouirages overutilization of ervices
-creates captive referral system auirednd limits competition

Question 13

OIG is required to exlude?

Answer 13

-medicare or medicaid fraud
- patient abuse or neglect
-feloy convicrtions relating to controlled substances

Question 14

OIG may exclude?

Answer 14

-misdeamaneor
-suspension/revocations
-unlawful kickbacks
-defaulting on heatlh education loan