Test 5 Part 22 Flashcards
Billing for services that were never rendered
Billing for more expensive services or procedures than were actually provided—upcoding
Performing medically unnecessary services
Misrepresenting noncovered treatments as medically necessary
Falsifying a patient’s diagnosis to justify tests or procedures
Unbundling
Billing patients more than the copay amount for services
Accepting kickbacks for patient referrals
Waiving patient copays or deductibles and overbilling the health plan (NHCAA
Types of Fraud and Abuse
Supervision of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenues
Revenue cycle management
Documentation must support the billing
Claims, requests for reimbursement, and supporting documentation must be complete and accurate
Reflect reasonable and necessary services ordered by an appropriately licensed medical professional
Role of documentation
Primary litigation tool for combating fraud, contains both criminal and civil provisions
False Claims Act (FCA) 1986
Private persons known as relators may enforce the False Claims Act (FCA) by filing a complaint alleging fraud committed against government
Qui tam (whistleblower)
Provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other way discriminated against
False Claims Act (FCA)
What constitutes a ________?
1) Furnishing inaccurate or misleading information to obtain payment
For example, upcoding
2) Omission of information from a claim
false claim
Provider must have knowingly submitted the false claim
Knowing Standard
_____ defines “knowing” and “knowingly” to mean that a person:
Has actual knowledge of falsity of information
Acts in deliberate ignorance of truth or falsity of information
Acts in reckless disregard of truth or falsity of information
FCA
Fraud Enforcement and Recovery Act of 2009 a _________ to FCA.
Revision
