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Ethics > Preventing Fraud, Abuse, Waste > Flashcards

Preventing Fraud, Abuse, Waste Flashcards

1
Q

Fraud, waste, abuse results in

A
  • Over utilization of services
  • increased cost for payers
  • corruption of medical decision making
  • unfair competition
  • harm to pt
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2
Q

Fraud

A

Intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled

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3
Q

Examples of fraud

A

Knowingly billing for services not furnished
Knowingly altering claims forms to receive more payment
Falsifying documents

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4
Q

Abuse

A

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

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5
Q

Examples of abuse

A

Billing services that are not medically necessary
Unbundling services and billing
Billing services that do not meet professionally recognized standards

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6
Q

Waste

A

Incurring incessant costs as a result of deficient management practices, systems, or controls

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7
Q

Examples of waste

A

Duplication of services already provided elsewhere

Spending on services that lack evidence of producing better outcomes compared with less-expensive alternatives

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8
Q

Major fraud and abuse laws

A
  • false claims act
  • federal anti-kickback statute
  • physical self-referral law
  • exclusion authorities
  • civil monetary penalty law
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9
Q

False claims back prohibits

A

The knowing submission of false claims or the use of false record or statement for payment to Medicare or Medicaid

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10
Q

False claims act monetary penalties

A

Between $5500 and $11000 per claim, plus 3 times the damages sustained by the government

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11
Q

False claims act sanctions

A

License sanctions and exclusions from federal program (you can be black listed)

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12
Q

“Knowing” under false claims act

A

Includes actual knowledge, deliberate ignorance, and reckless disregard for the truth or falsity of the information (you can’t choose to ignore information)

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13
Q

False claims act and whistleblowers

A

Strong incentive to report—-up to 30% of recovery

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14
Q

Who can be a false claim act whistleblower?

A

Ex-business partners
Staff
Competitors
Patients

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15
Q

Anti-kickback stature prohibits

A

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)

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16
Q

Anti-kickback statute payment includes

A

Anything of value

-cash for referrals, free rent, gifts, etc

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17
Q

Kickback examples

A

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

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18
Q

Physical self-referral law

A

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)

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19
Q

Stark laws

A

Is there a referral by a physician for a designated health service payable by Medicare?—> then does the physician have a financial relationship with the entity furnishing the DHS? —> if so, does the financial relationship if in an exception?—>if not, there is a violation

20
Q

Exclusion statue for physician self-referral law

A

The government may exclude inviolate providers from participation in federal health care programs meaning:

  • provider may not pill for txing pts
  • employer may not bill for the provider’s service
21
Q

PT relationship with payers

A
  • coding and billing
  • documentations
  • enrollment
22
Q

Coding and billing for PT

A
  • payers rely on PT to submit proper claims for payment c accurate info
  • when fed gov pays for services for Medicare/Medicaid beneficiaries, federal fraud and abuse laws apply
  • for private payers, states may have similar laws that apply
23
Q

Examples of improper coding and billing

-billing for services:

A
  • not provided
  • that are not medically necessary
  • provided by an aide
  • provided by PTAs not properly supervised
24
Q

Documentation is

A

A professional responsibility and legal requirement.
A record of patient care
Communication vehicle among providers

25
Q

Documentation: PTs must

A

Support the claims they submit with complete medical records and documentation

26
Q

Documentation: payers may

A

Review the medical records to verify the claims and quality of care through audits

27
Q

PT documentation demonstrates

A
  • compliance with federal, state, payer, and local regulations
  • appropriate utilization
28
Q

Medicare has ID following problems with PT documentation missing

A

Or incomplete POC
physicians sig and dates
total time for procedures and modalities
Certification and recert of POC

29
Q

Enrolling as Medicare/Medicaid provider

PT in private practice

A

Should individually enroll in federal health care programs to be paid for services to Medicare/Medicaid beneficiaries

30
Q

PTs enrolled in Medicare/Medicare are

A

responsible for making sure correct claims are submitted and for updating enrollment for any changes

31
Q

If a health care business offers something for free or below fair market value, or offers cash in exchange for referrals, question:

A
  • am I getting paid by company for very little work? Do they need my expertise?
  • does the amount of money I am offered seem appropriate for services I am going to provide?
  • am I being asked to refer pts to that particular company?
32
Q

Rental of office spay from physicians

A
  • do not pay for more space than necessary

- do not pay greater than fair market value

33
Q

Medical directors

A
  • should actively oversee clinical care, be involved
  • should be paid fair market value
  • should spend an appropriate amount of time providing services
34
Q

Gifts to physicians

A

Can be considered an inducement to refer patients to your practice
-stark II law allows nominal gifts
Analyze on case by case bases (education? Intent to induce referrals?)

35
Q

PT relationship with pts

A

Gifts to pts
Waiver of coinsurance
Collecting cash from Medicare beneficiaries

36
Q

Gifts to Medicare/Medicaid beneficiaries

A

Federal laws generally prohibit this

Seen as inducing a patient to come to your practice instead of another

37
Q

Inexpensive gifts allowed to pts if

A

Not cash or cash equivalents
AND
Value no more than $10 individually/$50 in aggregate annually per pt

38
Q

Why is providing free services to pts or waiving coinsurance/deductibles generally prohibited?

A

May influence a pt to receive your services (anti-kickback)

-exception for financially needy pts

39
Q

Exceptions to discounts/waiver violations

A

-provider ones not advertise discounts or waivers of copay
-provider does not routinely waive copays
-provider shows extensive efforts to collect money from pt
OR
-pt meets federal poverty guidelines or facility-specific poverty/catastrophic guidelines

40
Q

Exceptions for discounts: OIG and HHS issued letters to hospitals 02/04

A

Discount to uninsured and underinsured okay
Must establish policy and apply it uniformly
Documentation important

41
Q

Medicare and out of pocket

A

PT may not collect out of pocket payment from Medicare beneficiary for a service Medicare would cover (claim submission requirements under Medicare)
Only exception: physician that agree to opt out and not bill Medicare for 2 years

42
Q

Compliance programs

A

Prevent fraud, abuse, waste

Guidance is available for OIG

43
Q

Core elements of compliance program 1-4

A
  1. Written standards of conduct, policies, and procedures
  2. Designation of a compliance officer
  3. Effective education and training programs
  4. Hotline to receive complaints
44
Q

Core elements of compliance program 5-7

A
  1. System to repsonse to allegations of improper and or illegal activities
  2. Audits to monitor compliance
  3. Investigation and remediation of identified systematic problems
45
Q

What to do if there is a compliance problem

A
  • contact compliance officer
  • immediately stop submitting problematic bills
  • Seek knowledgeable legal counsel
  • determine whether there are any overpayments that need to be returned
  • disentangle yourself form problematic relationship
  • when appropriate consider reporting info to OIG or CMS

Ethics (2 decks)

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