Preventing Fraud, Abuse, Waste Flashcards
Fraud, waste, abuse results in
- Over utilization of services
- increased cost for payers
- corruption of medical decision making
- unfair competition
- harm to pt
Fraud
Intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled
Examples of fraud
Knowingly billing for services not furnished
Knowingly altering claims forms to receive more payment
Falsifying documents
Abuse
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
Examples of abuse
Billing services that are not medically necessary
Unbundling services and billing
Billing services that do not meet professionally recognized standards
Waste
Incurring incessant costs as a result of deficient management practices, systems, or controls
Examples of waste
Duplication of services already provided elsewhere
Spending on services that lack evidence of producing better outcomes compared with less-expensive alternatives
Major fraud and abuse laws
- false claims act
- federal anti-kickback statute
- physical self-referral law
- exclusion authorities
- civil monetary penalty law
False claims back prohibits
The knowing submission of false claims or the use of false record or statement for payment to Medicare or Medicaid
False claims act monetary penalties
Between $5500 and $11000 per claim, plus 3 times the damages sustained by the government
False claims act sanctions
License sanctions and exclusions from federal program (you can be black listed)
“Knowing” under false claims act
Includes actual knowledge, deliberate ignorance, and reckless disregard for the truth or falsity of the information (you can’t choose to ignore information)
False claims act and whistleblowers
Strong incentive to report—-up to 30% of recovery
Who can be a false claim act whistleblower?
Ex-business partners
Staff
Competitors
Patients
Anti-kickback stature prohibits
Anyone from knowingly or 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 (applies to both payer and recipient)
Anti-kickback statute payment includes
Anything of value
-cash for referrals, free rent, gifts, etc
Kickback examples
Pt gives referrer free/discounted office space
DME pays cash/provides free/discounted equipment in exchange for “preferred vendor status”
PT discounts/waives patient payment responsibility
Physical self-referral law
Prohibits physical referrals for certain health care services when there is a financial relationship with an entities unless an exception applies (financial relationships include ownership and compensation)