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Healthcare Delivery- JD > Lec 10: Part 2: Fraud and Abuse > Flashcards

Lec 10: Part 2: Fraud and Abuse Flashcards

1
Q

What are some causes of improper payment?

A

1) Given funds you did not deserve
2) Poor documentation
3) Incorrect coding
4) Not justifying services

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2
Q

If you are a good PT, and do not have time to document, is this okay?

A

NO - you must justify what you billed in your documentation, especially if you get audited, this is important

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3
Q

How does the fraud prevention system work: Is everyone an equal target for audits?

A

NO

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4
Q

How does the fraud prevention system work: Who do they target?

A

New providers; concept profiling if you are overcharging in comparison to other PTs in the area

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5
Q

How does the fraud prevention system work: Data is _______ because there is a ____ of data out there. They will target the _______

A

Analyzed
Pool
Outliers

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6
Q

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?

A

FRAUD

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7
Q

Fraud or abuse? Which one is done with intent?

A

Fraud

Evidence that you knew you were doing something wrong

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8
Q

Billing dead people is what?

A

Fraud

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9
Q

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

A

Abuse

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10
Q

Fraud of abuse: is an inadvertent mistake?

A

Abuse

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11
Q

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)

A

False Claims Act

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12
Q

Qui tam actions are in what?

A

False Claims Act

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13
Q

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)

A

Anti-kickback statute

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14
Q

This involves safe harbor regulations

A

Anti-kickback statute

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15
Q

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)

A

Physician Self-Referral Law (Stark)

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16
Q

For physicians, they cannot profit from a business that they refer to. This is what?

A

Physician Self-Referral Law (Stark)

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17
Q

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

A

Criminal health care fraud statute

18
Q

This provision was extended by ACA to protect against retaliation

A

Whistleblower Statute

19
Q

What are general penalties for violating anti-fraud laws/statutes?

A

Fines
Prison
Exclusion from federal programs

20
Q

Healthcare organizations establish ___________ that set up standards to conform to local, state, and federal laws and regulations

A

Compliance programs

21
Q

Compliance programs enable providers and employers to reduce exposure to penalties and sanctions, and as a result improve______ and______ of services

A

Efficiency and quality

22
Q

Compliance programs are based on the type of ______ or ______

A

Provider or organization

23
Q

The OIG and DHHS have coding and billing guidelines for:

A 
Hospitals
Clinical labs
Physician and therapist offices
Home care organizations
SNF
Hospices
24
Q

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

A

False or inaccurate

25
Q

What are the benefits: Opportunity to _____ and prevent illegal and unethical activity early

A

Identify

26
Q

What are the benefits: Concretely demonstrate to employees and the community the company’s commitment to ________

A

Honest conduct

27
Q

What are the benefits: Create a ______ that allows employees to report real or potential problems

A

Methodology

28
Q

What are the benefits: Develop policies and procedures to allow prompt thorough investigations of allegations of ______

A

Misconduct

29
Q

What are the benefits: Reduce the organization’s exposure to ______ damages, _____ sanctions, and administrative ________

A

Civil
Criminal
Overpayments

30
Q

What are the benefits: Discourage employee _____ or _______ actions

A

Qui tam

Whistleblower

31
Q

What are the benefits: Allow for decisive and appropriate_______ actions

A

Corrective

32
Q

Some of the top compliance uses in PT:

A
  1. Services not medically necessary
  2. Services not provided or documented
  3. Unbundling or up-coding
  4. Time documentation inconsistent with service billed
  5. Inappropriate personnel
  6. Provider ID numbers misused
  7. Care below accepted standard
  8. Waving of co-pays of deductibles
33
Q

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

A

PT License

Supervision

34
Q

Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services when the service performed was ______ and did not constitute PT

A

Unskilled

35
Q

Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services that were ________, only partially _______, or not medically necessary

A

Never performed

Performed

36
Q

Types of Medicare/Medicaid fraud and abuse violations: Licensee, knowingly or unknowingly, billing the _______ for treatment

A

Incorrect code

37
Q

Why is so much effort invested in program integrity?

A

Paying for the right things

38
Q

Who can deliver PT services that can be billed under Medicare?

A

Physicians
PTs
PTAs
NPPs

39
Q

Billing incident-to means: (3)

A
  1. Billing for each therapy visit or incident
  2. Billing for physician services when service was provided by unlicensed therapist
  3. 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.
40
Q

What types of payment for referrals is acceptable under Medicare?

A

Equitable, sharing of profits that come out of a patient care in a business?

41
Q

What is a corporate integrity agreement?

A

This is your settlement

42
Q

What is the look back period for Medicare Recovery Audit Contractors?

A

3 years

Healthcare Delivery- JD (12 decks)

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