Medicare Fraud and Abuse Flashcards
Error
incorrect billing
Waste
medically unnecessary service
Abuse
improper billing practices (up-coding)
Fraud
billing for services or supplies that were not provided
Anti-kickback
you cannot pay for referrals (induce or reward)
offering, receiving or paying
Who is accountable for crime with anti-kickback law?
both parties
Anti-kickback penalties
felony fines up to $25,000 prison up to 5 years possible exclusion from Medicare program Possible False Claim Act (Medicare fraud and abuse liability)
Examples of safe harbors:
investment interests space and equipment rental personal service warranties discounts referral services
Ways to protect from safe habor
arms length contract
fair market value
Civil False Claims Act
Is the statute under which Medicare/Medicaid fraud is prosecuted
Elements of Civil False Claims Act:
Submission of a claim for payment to Medicare
Claim was false or fraudulent
Claimant acted knowingly
Also prohibited by Civil False Claims Act:
Using a false record to secure payment for a claim
Conspiring to secure payment for a false claim
False Claims Act Penalties:
Triple the amount of damages which the government sustained because of the act of that person
Civil penalties with false claims act:
$10,781-21,563 for each false claim
Stark 2 Law:
Intent was to prevent physician ownership of PT/OT clinics, DME companies, oxygen suppliers, and hospital inpatient or outpatient services
Intent to prevent referral for profit
Stark 2 Law exceptions:
Physicians can own PT and OT clinics as long as those clinics are within the physician clinic and the physician bills those services as “incident to” his/her own
They must be performed by a PT, OT, or SLP
PTAs cannot work directly for a physician and bill Medicare
Malfeasance
doing something stupid that one is not supposed to do (e.g., practice outside the practice act)
Misfeasance
doing something stupid (e.g., ultrasound on the temple)
Nonfeasance
should have taken action but did not (e.g., did not refer to emergency room when necessary)
Gross negligence
intentional or reckless omission
Intentional tort
4 elements of negligence
Duty of Care
Breach of Duty of Care
Injury
Causation/Proximate Cause
Duty of Care
Legal relationship between the parties which imposes an obligation of care, performance, or observance
Breach of Duty of Care:
Is determined by the jury - did the defendant (provider) fail to meet his/her duty?
Injury
Loss of income
Medical expenses
Loss of reputation
Pain and suffering
Causation/Proximate Cause
Plaintiff must prove by a preponderance of the evidence that, absent the defendant’s negligent act, the plaintiff would not have been injured
Malpractice:
doing something wrong when the practitioner should have known how to do it correctly
What can be used to establish standard of care?
community standards
national standards (guide to practice)
expert witness opinion
Strict Liability:
Seller is liable for any and all defective or hazardous products or services which unduly threaten a consumer’s safety, regardless of fault
Applies even if the seller has exercised all possible care in the preparation and sale of his/her product/service
Respondeat Superior
The master is responsible for the actions of the servant”
Hospital/nursing home/clinic is held vicariously liable for torts committed within the scope of employment of their employees
Imputed Knowledge
Doctrine of respondeat superior attaches liability to the organization regardless of whether the employer has actual knowledge of the specific act
Title VII of Civil Rights Act of 1964:
Made it illegal for an employer to deny anyone a job because of: Race Color Religion Sex National Origin
Age Discrimination in Employment Act of 1976
Prohibits discrimination against individuals aged 40 or over
Enforced by EEOC
Equal Pay Act of 1963
Protects men and women who perform substantially equal work in the same establishment from sex-based wage discrimination
ADA
Prohibits employment discrimination against qualified individuals with a disability in the private sector and in state and local governments
Must make reasonable accommodation(s) to person if it is not an undue hardship to the organization
FMLA
Covered employers must grant an eligible employee up to a total of twelve (12) work weeks of unpaid leave during any 12-month period
Reasons covered for FMLA:
a. for the birth and care of the newborn child of the employee
b. for placement with the employee of a son or daughter for adoption or foster care
c. to care for an immediate family member (spouse, child, or parent) with a serious health condition
d. to take medical leave when the employee is unable to work because of a serious health condition
FMLA requirements:
a. Must have worked at organization for one (1) year
b. Must work for 1,250 hours in that calendar year
24 hours/week
Fair Labor Standards Act
Establishes minimum wage, overtime pay, recordkeeping, and child labor standards affecting full-time and part-time workers in the private sector and in Federal, State, and local governments
Qualifications for be salaried:
executive
administrative
professional
outside sales and computer employees
FLSA does NOT require employers to provide
a. vacation, holiday, severance, or sick pay
b. meal or rest periods, holidays off, or vacations
c. premium pay for weekend or holiday work
d. pay raises or fringe benefits
e. a discharge notice, reason for discharge, or immediate payment of final wages to terminated employees
