Lec 10: Part 2: Fraud and Abuse Flashcards
What are some causes of improper payment?
1) Given funds you did not deserve
2) Poor documentation
3) Incorrect coding
4) Not justifying services
If you are a good PT, and do not have time to document, is this okay?
NO - you must justify what you billed in your documentation, especially if you get audited, this is important
How does the fraud prevention system work: Is everyone an equal target for audits?
NO
How does the fraud prevention system work: Who do they target?
New providers; concept profiling if you are overcharging in comparison to other PTs in the area
How does the fraud prevention system work: Data is _______ because there is a ____ of data out there. They will target the _______
Analyzed
Pool
Outliers
Purposely billing for services that were not provided or were not medically necessary, billing for a higher level of service than what was provided, misreporting costs or other data to increase payments, paying or receiving kickbacks, illegally marketing products, and/or stealing providers’ or beneficiaries’ identities is what?
FRAUD
Fraud or abuse? Which one is done with intent?
Fraud
Evidence that you knew you were doing something wrong
Billing dead people is what?
Fraud
What is this: Practices that either directly or indirectly result in unnecessary costs to Medicare or Medicaid, including misuse of codes on a claim, charging excessively for services or supplies, and billing for services that were not medically necessary
Abuse
Fraud of abuse: is an inadvertent mistake?
Abuse
Civil liability for knowingly submitting or causing to be submitted a false or fraudulent claim to the federal government (documenting something when you did not do it, omitting information, not supporting claims)
False Claims Act
Qui tam actions are in what?
False Claims Act
Criminal offense to knowingly and willfully offer, pay, solicit, or receive remuneration or induce or reward referrals of items or services reimbursable by a Federal healthcare program (cannot pay a provider for referrals)
Anti-kickback statute
This involves safe harbor regulations
Anti-kickback statute
Prohibits referral for health services to an entity in which the physician (or member of immediate family) has ownership/investment interest or a compensation arrangement (exceptions apply)
Physician Self-Referral Law (Stark)
For physicians, they cannot profit from a business that they refer to. This is what?
Physician Self-Referral Law (Stark)
Prohibits knowingly and willfully executing or attempting to execute a scheme or artifice to defraud a healthcare benefit program, or to obtain (by false or fraudulent pretenses) any of the money or property owned by or in the custody of the healthcare program
Criminal health care fraud statute
This provision was extended by ACA to protect against retaliation
Whistleblower Statute
What are general penalties for violating anti-fraud laws/statutes?
Fines
Prison
Exclusion from federal programs
Healthcare organizations establish ___________ that set up standards to conform to local, state, and federal laws and regulations
Compliance programs
Compliance programs enable providers and employers to reduce exposure to penalties and sanctions, and as a result improve______ and______ of services
Efficiency and quality
Compliance programs are based on the type of ______ or ______
Provider or organization
The OIG and DHHS have coding and billing guidelines for:
Hospitals Clinical labs Physician and therapist offices Home care organizations SNF Hospices
What are the benefits: Fulfill legal duty to ensure that _____ or _____ claims for payment for services are not being submitted to government or private reimbursement sources
False or inaccurate
What are the benefits: Opportunity to _____ and prevent illegal and unethical activity early
Identify
What are the benefits: Concretely demonstrate to employees and the community the company’s commitment to ________
Honest conduct
What are the benefits: Create a ______ that allows employees to report real or potential problems
Methodology
What are the benefits: Develop policies and procedures to allow prompt thorough investigations of allegations of ______
Misconduct
What are the benefits: Reduce the organization’s exposure to ______ damages, _____ sanctions, and administrative ________
Civil
Criminal
Overpayments
What are the benefits: Discourage employee _____ or _______ actions
Qui tam
Whistleblower
What are the benefits: Allow for decisive and appropriate_______ actions
Corrective
Some of the top compliance uses in PT:
- Services not medically necessary
- Services not provided or documented
- Unbundling or up-coding
- Time documentation inconsistent with service billed
- Inappropriate personnel
- Provider ID numbers misused
- Care below accepted standard
- Waving of co-pays of deductibles
Types of Medicare/Medicaid fraud and abuse violations: Providing and billing for PT services without a _______ and/or without the appropriate _______ of a physician or licensed PT as required by federal and state law
PT License
Supervision
Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services when the service performed was ______ and did not constitute PT
Unskilled
Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services that were ________, only partially _______, or not medically necessary
Never performed
Performed
Types of Medicare/Medicaid fraud and abuse violations: Licensee, knowingly or unknowingly, billing the _______ for treatment
Incorrect code
Why is so much effort invested in program integrity?
Paying for the right things
Who can deliver PT services that can be billed under Medicare?
Physicians
PTs
PTAs
NPPs
Billing incident-to means: (3)
- Billing for each therapy visit or incident
- Billing for physician services when service was provided by unlicensed therapist
- These services relate to services furnished as an integral, although incidental, part of the physician’s personal professional services in the course of Dx or treatment of an injury or illness. A licensed HCP such as a PT may provide the required services under the physician’s direct supervision, and these services are billed by the physician.
What types of payment for referrals is acceptable under Medicare?
Equitable, sharing of profits that come out of a patient care in a business?
What is a corporate integrity agreement?
This is your settlement
What is the look back period for Medicare Recovery Audit Contractors?
3 years
