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Ethics > Fraud, abuse and waste > Flashcards

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
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2
Q

What is fraud?

A

Intentional deception or misrepresentation that a persin makes to gain a benefit to which they are not entitled

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3
Q

example of fraud

A
  • knowingly billing for services not furnished
  • knowingly altering claims forms to receive more payment
  • falsifying documentation
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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
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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
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6
Q

What is waste?

A
  • incurring unnecessary costs as a result of deficient management practices, systems or controls
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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

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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
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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
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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

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11
Q

whistleblowers incetive

A
  • strong incentive for whistleblowers to report fraud

- can receive up to 30 % of recovery

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12
Q

WHo can be a whistleblower?

A
  • ex-business partners
  • staff
  • competitors
  • patients
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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
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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
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15
Q

what is financial relationship?

A
  • financial relationships include ownership and compensation
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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
Q

relationships with referral sources and medical directors

A
  • should actively oversee clinical care, be involved
  • should be paid fair market value
  • should spend an appropriate amount of time providing services
26
Q

relationships with referral sources — gifts to physicians

A

-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
Q

Relationship with patients—- gifts to patient

A
  • federal laws generally prohibit gifts to medicare and Medicaid beneficiaries
  • –seen as inducing a patient to come to your practice instead of another
28
Q

relationships with patients—inexpensive gifts allowed if:

A

-not cash or cash equivalents; and value is no more than a $10 individually/ $50 in aggregate annually per patient

29
Q

relationship with patients

– waiver of coinsurance

A
  • 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
Q

exceptions to discounts or waiver violations

A
  • 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
Q

exception for discounts

A
  • 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
Q

collecting out-of -pockets payment from medicare

A
  • 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
Q

compliance programs

A
  • compliance programs can prevent fraud, abuse, and waste
  • voluntary compliance program guidance is available from OIG
  • 7 core elements for a compliance program
34
Q

7 core elements of a compliance program

A

1 written standard of conduct, policies and procedures

  1. designation of a compliance officer
  2. effective education and training programs
  3. hoyline to receive complaints
  4. system to respond to allegations of improper and/or illegal activities
  5. audits to monito compliance
  6. investigation and remediation of identified systemic problems
35
Q

what to do if there is problem??

A
  • 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

Ethics (3 decks)

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