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Financial Management in Healthcare1 | P a g eFinancial Management in HealthcareCivil Monetary Penalties: Fraud, Waste, and AbuseBy: Trina Calloway-Peden
Financial Management in HealthcareName of the Law and or laws:Social Security Act-Civil Monetary Penalties law [42 U.S.C. § 1320a-7a]OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conductand is authorized to seek different amounts of penalties and assessments based on the type ofviolation at issue. Penalties range from $10,000 to $50,000 per violation. Some examples ofCMPL violations include: presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent; presenting a claim that the person knows or should know is for an item or service for which payment may not be made; violating the AKS; violating Medicare assignment provisions; violating the Medicare physician agreement; providing false or misleading information expected to influence a decision to discharge; failing to provide an adequate medical screening examination for patients who present to a hospital emergency department with an emergency medical condition or in labor; and making false statements or misrepresentations on applications or contracts to participate in the Federal health care programsManagement’s Financial Responsibilites:Management’s financial responsibility under this statue for administrative enforcement authorities is to grant OIG timely access to records, upon reasonable request which could cost thehealth organization up to $15,000 per day. If the health organization or provider continues to order or prescribe while excluded from participating in federal health care programs, this is couldcost up to $10,000 per violation. If making or using a false record or statement that is material toa false or fraudulent claim it could cost the health care organization up to $50,000 for each false record or statement. Health organizations are responsible for knowing updates to the regulations regarding the Civil Monetary Penalties for all laws pertaining to fraud, waste, and abuse. The Affordable Care Act has increased the penalties for all the laws as to Nov. 2, 2015 and health 2 | P a g e
Financial Management in Healthcareorganizations are responsible for knowing the violation increase as stated in 81 Fed. Reg. 61538(Waltz, n.d):$15,000 Stark Law violation CMP is now $23,863.$100,000 Stark Law circumvention scheme CMP is now $159,089.$50,000 AKS CMP is now $73,588.$50,000 EMTALA CMP is now $103,139.Consequences for Ethical or Legal Breach:The Office of Inspector General (OIG) has the authority to seek civil monetary penalties (CMPs),assessments, and exclusion against an individual or entity based on a wide variety of prohibited conduct. In each CMP case resolved through a settlement agreement, the settling party has