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Fraud and Abuse
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Definitions of Fraud and Abuse Acts of providers that are deemed to have defrauded the government or abused the right to bill for services rendered The distinction between fraud and abuse is not always clear The degree of intent by the individual or entity under investigation is often the determining factor
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What is Fraud? Fraud is defined as knowingly and willfully executing or attempting to execute, a scheme to defraud any health care benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program
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Common Examples of Fraud Billing for services not provided Billing for services as if performed by the physician when they were in fact performed by someone else Using an incorrect or inappropriate provider number in order to be paid Selling or sharing patients’ Medicare numbers Falsifying information on medical records, billing statements, or other statements to the government
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Common Examples of Fraud Misrepresenting the diagnosis to justify payment Unbundling or exploding charges Paying or receiving remuneration or kickbacks for referrals Violation of federal and state statutes relating to self-referrals Billing based on what is often referred to as “gang” visits Inappropriate billing for teaching physicians
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Common Examples of Fraud Misrepresenting the identify of the person receiving services Deliberately changing dates of service to circumvent correct coding edits Falsely applying for Medicare or Medicaid certification by falsification of address, or misrepresentation of credentials Reporting an incorrect place of service Ghost patients
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What is Abuse? Abuse may directly or indirectly result in unnecessary costs to a program such as Medicare or Medicaid, improper payment, or payment for services that fail to meet professionally recognized standards of care or that are medically unnecessary Typically, the physician or other health care professional has not knowingly and willfully misrepresented facts to obtain payment
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Common Examples of Abuse Performance of services considered by the carrier to be medically unnecessary Failure to document medical records adequately Unintentional, inappropriate billing practices such as misuse of modifiers Medicare limiting charge violations Failure to comply with a participation agreement Inadvertent filing of duplicate claims
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Sources of Information on Fraud and  Abuse Complaints from the public Disgruntled employees Third party payer reviews Competitors Medical boards Beneficiaries
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Fraud and Abuse Statutes Federal False Claims Act Allows the government or citizens to bring civil action or criminal action against physicians and others filing fraudulent claims Provides for a civil penalty of $11,000 per false claim,
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