Efforts to combat fraud were consolidated and strengthened under
Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
. The Act established a comprehensive program to combat fraud committed against all health plans, both public and private.
What is healthcare fraud prevention?
The Healthcare Fraud Prevention Partnership (HFPP) is
a voluntary public-private partnership that helps detect and prevent healthcare fraud through data and information sharing
.
What is the Stark Law in healthcare?
The Stark law
prohibits a physician’s referral for certain designated healthcare services (DHS) to an entity if the physician (or a member of the physician’s immediate family) has a financial relationship with the entity
, unless the referral is protected by one or more exceptions provided in the law.
What is the government’s most powerful health care fraud fighting tool?
This coordinated takedown is the largest in history, both in terms of the number of defendants charged and loss amount. Another powerful tool in the effort to combat health care fraud is the
federal False Claims Act
.
What are the major types of healthcare fraud and abuse?
Some of the most common types of fraud and abuse are misrepresentation of services with incorrect Current Procedural Terminology (CPT) codes; billing for services not rendered; altering claim forms for higher payments; falsification of information in medical record documents, such as International Classification of …
What is Qui Tam in healthcare?
A qui tam lawsuit is
one filed by an individual whistleblower as part of the False Claims Act (FCA), a law punishing people or organizations who file false claims for funds from government programs
.
What are CMS guidelines for referrals?
In a CMS compliant situation, you would 1)
ask for referrals without mentioning any benefit to the enrollee
and then 2) present a thank-you gift for the referrals he or she has provided. Second, the gifts you provide must be of a nominal value.
What is Medicare regulation?
Medicare Regulations means, collectively, all federal statutes (whether set forth in Title XVIII of the Social Security Act or elsewhere) affecting Medicare, together with all applicable provisions of all rules, regulations, manuals and orders and administrative, reimbursement and other guidelines having the force of …
When was the health care fraud Prevention and Enforcement Action Team created?
The Health Care Fraud Prevention and Enforcement Action Team is an organization that was created in
May of 2009
by the U.S. Department of Health and Human Services, the U.S. Department of Justice, and the Office of Inspector General to address healthcare fraud and its prevention.
Was developed by the federal government to reduce or eliminate fraud in healthcare?
Efforts to combat fraud were consolidated and strengthened under Public Law 104-191,
the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
. The Act established a comprehensive program to combat fraud committed against all health plans, both public and private.
What is healthcare provider fraud?
Health-care fraud occurs
when a health-care professional knowingly, willfully, and intentionally makes a false statement or claim
. Making false statements or documentation to obtain program benefits, such as Medicare reimbursement when a provider would otherwise not be entitled to payment, is fraudulent.
What are the examples of healthcare fraud?
Some examples of consumer health care fraud are:
filing claims for services or medications not received; forging or altering bills or receipts; using someone else’s coverage or insurance card
.
What is medical coding fraud?
Coding fraud involves
the knowing submission of claims to government insurers with incorrect billing codes, diagnostic codes, units of service, dates of service, or service providers
.
What is the False Claims Act in healthcare?
The False Claim Act is
a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program
, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded …
Is qui tam civil or criminal?
A qui tam lawsuit is a lawsuit brought by a whistleblower to enforce the federal False Claims Act or analogous state statutes, laws that impose
civil liability
on persons or companies who knowingly make or cause others to make false claims for the payment of government funds.
When was the False Claims Act enacted?
Many of the Fraud Section’s cases are suits filed under the False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733, a federal statute originally enacted in
1863
in response to defense contractor fraud during the American Civil War.
A referral is issued by a primary care physician (PCP) for the patient to see a specialist. In contrast, prior authorization is issued by the payer (an insurance provider), giving a medical practice or physician the approval to perform a medical service.
•
A formal process that authorizes an HMO member to get care from a specialist or hospital
. Most HMOs require patients to get a referral from their primary care doctor before seeing a specialist.
Can I give gifts for Medicare referrals?
1. Gifts To Referral Sources. The federal Anti-Kickback Statute (“AKS”) prohibits soliciting, offering, giving, or receiving remuneration in exchange for referrals for items or services covered by federal healthcare programs (e.g., Medicare and Medicaid) unless the arrangement fits within a regulatory exception.
Who regulates Medicare?
The federal agency
that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP).
What is the CMS Administration?
Administrator. Chiquita Brooks-LaSure is the
Administrator for the Centers for Medicare and Medicaid Services
(CMS), where she will oversee programs including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the HealthCare.gov health insurance marketplace.
