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
