Fraud/Abuse Flashcards
intentional deception or intentional misrepresentation that a provider makes to gain a benefit for which that provider is not entitled
fraud
examples:
knowingly billing for services that were not provided
knowingly altering claim forms to receive a higher payment amount
falsifying documentation
examples of fraud
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
abuse
misusing codes on a claim
billing for services that were not medically necessary
unbundling and billing individual components of a service instead of the all inclusive procedure
abuse
overutlization of services or other practices that directly or indirectly result in unnecessary cost to the health care system. not criminally negligent actions but by payment errors or misuse of resources
waste
T or F due to the complexity of the system waste is much more common than fraud or abuse
true
imposes liability on any person who submits a claim to cms that he/she knows is false
false claims act
not subject to statute because they are unlikely to result in fraud of abuse
describe conduct that is explicitly permissible- conduct is fully protected from liability under statute
safe harbors
criminal offense to knowingly and willfully offer, pay, solicit or receive bribes or kickbacks to induce or reward referrals in order to induce business reimbursable
anti-kickback statute
physician referring a patient to a facility in which he or she has a financial interest be it ownership, investment or family members ownership
physician self referral law stark
inherent conflict of interest given the physicians position to benefit from such referral
physician self referral law stark
is there a list of exceptions that may exclude a physician from coverage under stark
yes
In- office ancillary service do what
allow internal referral
intended to mean same day services for convenient urgent care
interpreted to mean you can employ a PT and supervise
- does this arrangement involve a referral of a medicare or medicaid patient by physician or an immediate family member of a physician
- is the referral a designated health service
- is there a financial relationship of any kind between the referring physician or a family member and the entity in which the referral is being made?
questions to ask to determine whether the stark statute applies to a particular arrangement
what is the exclusion statute
excluded from doing business with medicare due to abuse, felony convictions
where doe medicare physical therapy treatments average more than 60 treatments/year
new york
miami
houston
batton rouge
what is the key factor that make crime fraud instead of abuse
intention
why are there so many fraud/abuse problems in federal payers?
cause thats where the money is
are federal gov prosecutions for fraud increasing or decreasing
fraud recovery is increasing
what is the exlusion statute
spells out circumstances which a certain individual or entities can be banned from federal health care programs
what is a safe harbor
a legal provision in a statute or regulation that provides protection from legal liability when certain conditions are met
what is okay in hipaa
treatment sharing between professionals who share a patient
no restrictions or limitations whatsoever for treatment absent a referral
20 states including colorado
unrestricted patient access
time or visit limit
prohibits certain diagnosis/treatment without referral
requires continuing education connected to access
patient access with provisions
access to evaluation only, fitness and wellness, limited treatment only certain patient populations under certain circumstances
limited patient access
Does medicare take direct access
yes but just need a signature on the pt POC
how does having a physician referral impact the physical therapist liability
does not change the liability
are physical therapists allowed to refer for imaging
yes in colorado and wisconson more states are gaining access
who should we be referring more too
dietitians
councelors/psychologist
what 3 professions can claim they do phsyical therapy
chiropractors
physical therapists
physicians
