Fraud, abuse and waste Flashcards
1
Q
fraud abuse and waste results in:
A
- overutilization of services
- increased costs for payers
- corruption of medical decision makinh
- unfair competition
- harm to patient
2
Q
What is fraud?
A
Intentional deception or misrepresentation that a persin makes to gain a benefit to which they are not entitled
3
Q
example of fraud
A
- knowingly billing for services not furnished
- knowingly altering claims forms to receive more payment
- falsifying documentation
4
Q
What is abuse?
A
- payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment
5
Q
example of abuse
A
- billing services that not medically necessary
- unbundling services an dbilling
- billing services that do not meet professionally recognized standards
6
Q
What is waste?
A
- incurring unnecessary costs as a result of deficient management practices, systems or controls
7
Q
example of waste
A
- duplication of services already provided elsewhere
- spending on services that lack evidence of producing better outcomes compared with less expensive alternatives
8
Q
major fraud and abuse laws
A
- false claims act
- federal anti-kickback statute
- physician self-referral law
- exclusion authorities
- civil monetary penalty law
9
Q
false claims act
A
- prohibits the knowing submission of false claims or the use of a false record or statement for payment to medicare or Medicaid
- monetaries penalties of between &5,500 and 11,000 per claim, plus 3 times the damages sustained by the government
- license sanctions and exclusion from federal program
10
Q
What is “knowing” under false claims act?
A
- “knowing” includes actual knowledge, deliverate ignorance, and reckless disregard for the truth or falsity of the info
— can’t choose to ignore the information
11
Q
whistleblowers incetive
A
- strong incentive for whistleblowers to report fraud
- can receive up to 30 % of recovery
12
Q
WHo can be a whistleblower?
A
- ex-business partners
- staff
- competitors
- patients
13
Q
anti-kickback statue
A
- prohibits anyone from “knowingly and willfully” offering or receiving a form of payment in return for referring a patient to another provider for services or items covered by Medicare and Medicaid
- payment can include anything of value
- safe harbors permit nonabusive arrangements
14
Q
Physician self-referral law
A
- prohibits physician referrals for certain health care services when there is a financial relationship with an entity unless and exeption applies
15
Q
what is financial relationship?
A
- financial relationships include ownership and compensation
16
Q
exclusion statue
A
the government may exclude inviolate providers from participation in federal health care programs:
- — the provider may not bill for treating patients
- — an employer may not bill for the provider’s services
17
Q
coding and billing for PT
A
- payers rely on PT to submit proper claims for payment with accurate info
- when the federal government pays for services for medicare and Medicaid beneficiaries, federal fraud and abuse laws apply
- for private payers, states may habe similar laws that apply
18
Q
example of coding and billing for PT
A
- billing for services not provided
- billing for services that are not medically necessary
- billing for services provided by aides
- billing for services provided by PTSs not properly supervised
19
Q
PT DOcumentation
A
- Professional responsibility and legal requirement
- PT must support the claims they submit with complete medical records and documentation
- payers may review the medical records to verify the claims and quality of care through audits
20
Q
what is documentation?
A
- is a record of patient care
- is a communication vehicle among providers
- demonstrates compliance with federal, state, payer, and local regulations
- can demonstrate appropriate utilization
21
Q
Common medicare documentation mistake
A
- missing or incomplete plan of care
- missing physician signatures and dates
- missing total time for procedures and modalities
- missing certification and recertification of plan of care
22
Q
enrolling as a medicare and Medicaid provider
A
- PT in private practice should individually enroll in the federal health care programs to be paid dor in services to medicare beneficiaries
- enrolled PTs are responsible for making sure correct claim are submitted an for updating enrollment for any changes
23
Q
What counts as relationships with referral sources
A
-If a health care business offers something for free or below fair market value, or offers cash in exchange for referrals, question the reason
24
Q
When we encounter rental of office space from physicians?
A
- Do not pay for more space than necessary
- do not pay greater than fair market value
25
relationships with referral sources and medical directors
- should actively oversee clinical care, be involved
- should be paid fair market value
- should spend an appropriate amount of time providing services
26
relationships with referral sources --- gifts to physicians
-CAUTION! gifts should be considered an inducement to refer patients to your practice
- Stark II law allows nominal gifts
- Analyze gifts case-by -case
27
Relationship with patients---- gifts to patient
- federal laws generally prohibit gifts to medicare and Medicaid beneficiaries
- --seen as inducing a patient to come to your practice instead of another
28
relationships with patients---inexpensive gifts allowed if:
-not cash or cash equivalents; and value is no more than a $10 individually/ $50 in aggregate annually per patient
29
relationship with patients
| -- waiver of coinsurance
- Providing free services to patients or waiving coinsurance and deductibles is generally prohibited as it may influence a patient to receive your services
- there is an exception for financially needy patients
30
exceptions to discounts or waiver violations
- provider dows not advertise discounts or waivers of copays
- provider does not routinely waive copays
- provider shows extensive efforts to collect money from patient OR
- -- patient meedts federal poverty guidelines or facility-specific poverty/ catastrophic guidelines
31
exception for discounts
- OIG and HHS issued letters to hopsitals 02/04
- discounts to uninsured and underinsured okay
- must establish a policy and apply it uniformly
-documentation important
32
collecting out-of -pockets payment from medicare
- a PT may not collect out-of-pocket payment from a medicare beneficiary for a service that medicare would cover
- there are claims submission requirements under medicare for covered services
33
compliance programs
- compliance programs can prevent fraud, abuse, and waste
- voluntary compliance program guidance is available from OIG
- 7 core elements for a compliance program
34
7 core elements of a compliance program
1 written standard of conduct, policies and procedures
2. designation of a compliance officer
3. effective education and training programs
4. hoyline to receive complaints
5. system to respond to allegations of improper and/or illegal activities
6. audits to monito compliance
7. investigation and remediation of identified systemic problems
35
what to do if there is problem??
- contact the compliance officer
- immediately stop submitting problematic bills
- seek knowledgeable legal counsel
- determine whether there are any overpayments that need to be returned
- disentangle yourself from problematic relationshio
- when appropriate, consider reporting info to OIG or CMS
