Fraud
Reporting a health care claim for medical services, using an incorrect procedure code that results in greater payment than what is deserved is a violation of the:
False Claims Act of 1863
Credit balances that occur when payments and allowances exceed the amount of the charge, can be held by the health care organization, and used towards a future service. True of False
False
a federal statute originally enacted in 1863 in response to defense contractor fraud during the American Civil War. It is when someone knowingly uses a false record material to a false claim or improperly avoids an obligation to pay the government
False Claims Act
Private individuals who acts as an informant and reports suspected fraud on behalf of the federal government is referred to as a:
Relator
Clinical laboratories must be certified to be able to run certain levels of test, as directed under the Clinical Laboratory Improvement Amendments. also known as?
CLIA
Billing for services or supplies that were not provided is considered
medical Necessity Fraud?
law that prohibits offering or receiving anything of value ("remuneration") to induce or reward patient referrals for services reimbursed by federal healthcare programs like Medicare or Medicaid, ensuring medical decisions aren't driven by financial incentives, covering cash, gifts, lavish trips, and more, with severe penalties including jail time and fines for violators.
Anti-Kickback Statute
A health care organization’s compliance plan outlines:
their standardized process for handling business functions
The Office of Inspector General has issued compliance program guidelines for various types of health care organizations which is published in the
Federal Register
regulations describe various payment and business practices that, although they potentially implicate the Federal anti-kickback statute, are not treated as offenses under the statute.
Safe Harbor
If an insurance billing specialist has questions or concerns regarding billing of claims that may be considered fraudulent, they should bring the concern to:
the organization’s compliance office
A provider knowingly and willfully solicits or receives payment or bribes in exchange for the referral of Medicare or Medicaid patients.
What is a kickback?
financial fine imposed by a government agency for violating laws or regulations, distinct from criminal charges, intended to deter illegal behavior, recover economic gains, and ensure compliance in areas like healthcare, environmental, and securities law, with penalties varying by agency and violation type.
Civil Monetary Penalty
The penalties for violating the health care fraud laws are updated regularly and published in the
Federal register
Legislation which prohibits the submission of claims for services or referral of patients if the referring provider has financial interest with the entity that provides the service.
What is Stark Law