Fraud and Abuse

Fraud and Abuse - really done 2 Upcoding Legal Effect...

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1. Kickbacks 2. False Claims 3. Self Referral Issue can be raised that falls under more than one category => Crime to knowingly defraud a public or private health plan.    False Claims Act : Civil Law that allows whistle blowers to receive a reward for identifying  groups that are cheating the government.    Difficult for the government to purchase health care: Services, not goods that can be inspected Not delivered to agents of the gov, delivered to grandma an grandpa Delivered at hospitals, offices, homes (not gov facilities) Hard to determine if service was done well   False Claims:  1. Requesting payment for services not provided (to pts not really seen, or for things not 
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Unformatted text preview: really done) 2. Upcoding Legal Effect - depends on the provider's knowledge and intent--> Can violate Criminal Law Category State of Mind Legal Standard Penalty Mistake Honest / Careless Mistake / Negligence None --> Return money Criminal Fraud Intent to defraud Knowing and willfully made false statement Felony = 5 years Beyond a Reasonable Doubt Civil False Claims Act Knowingly presented a false claim Definitions of Knowingly: = Actual knowledge = Deliberate ignorance = Reckless disregard = $5,000-$10,000 + treble damages , with so much at stake it is not worth even a small risk of losing in court so often have to settle...
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