Fraud and Abuse Flashcards
What is a mistake or error for medicare?
incorrect coding
What are inefficiencies or waste according to medicare?
providing medically unnecessary service
What is bending the rules or abuse according to medicare?
improper billing practice like upcoding
What is intentional deception of fraud according to medicare?
billing for services that were not provided
What is the medicare anti-kickback statute?
knowingly, indirectly or directly, paying for referrals
Who is responsible for kickback?
both parties involved
What are the penalties for kickback?
up $25,000 and or 5 years in prison; exclusion from medicare
What are safe harbors?
renting a space you own out to someone for a decreased rate for referrals (have to put at a fair market value)
What should one always do when operating with safe harbors?
arms length contract or agreement (written); fair market value
What should we know in relation to Medicare Billing?
all rules and regs applicable to services billed by the provider and or on behalf of the provider.
What can result from falsification of Medicare billing?
can be punished by criminal, civil, or administrative penalties or imprisonment
What is the civil false claims act?
the statue under which medicare/medicaid fraud is prosecuted.
What are the required elements for submission under the civil false claims act?
- submission of a claim for payment to medicare
- claim that was false or fraudulent
- clamant acted knowingly
What are possible penalties for false claims?
fines and jail time
What are Qui Tam Actions?
whistleblower lawsuits where employees report employers. (blower can potentially collect if case goes through)
What are corporate compliance programs?
internal programs that help an organization avoid fraud and monitor for safety of the organization over the individual
Where must profits of a NFP organization go?
back into the organization
Can a physician own a PT or OT clinic?
yes, as long as it is within their clinic and bills services as their own; services must still be provided by the proper professional
Can a PTA work directly for a physician?
no, must work under a licensed PT
What is malfeasance?
doing something stupid that one is not supposed to do (practice outside of practice act)
What is misfeasance?
doing something stupid (US on the temple)
What is nonfeasance?
should have taken action but did not (did not refer to ER when necessary
Ordinary vs. gross neglicence?
Ordinary: a reasonable man would have known
Gross: intentional or reckless omission
What is required to prove negligence?
- Duty of Care (legal obligation for care and performance
- breach of duty of care
- Injury (loss of income or reputation; pain/suffering/ medical expenses)
- Causation/Proximate Cause (plaintiff must prove it)
