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Flashcards in Medicare Fraud and Abuse Deck (40)
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1

Error

incorrect billing

2

Waste

medically unnecessary service

3

Abuse

improper billing practices (up-coding)

4

Fraud

billing for services or supplies that were not provided

5

Anti-kickback

you cannot pay for referrals (induce or reward)
(offering, receiving or paying)

6

Who is accountable for crime with anti-kickback law?

both parties

7

Anti-kickback penalties

felony
fines up to $25,000
prison up to 5 years
possible exclusion from Medicare program
Possible False Claim Act (Medicare fraud and abuse liability)

8

Examples of safe harbors:

investment interests
space and equipment rental
personal service
warranties
discounts
referral services

9

Ways to protect from safe habor

arms length contract
fair market value

10

Civil False Claims Act

Is the statute under which Medicare/Medicaid fraud is prosecuted

11

Elements of Civil False Claims Act:

Submission of a claim for payment to Medicare
Claim was false or fraudulent
Claimant acted knowingly

12

Also prohibited by Civil False Claims Act:

Using a false record to secure payment for a claim
Conspiring to secure payment for a false claim

13

False Claims Act Penalties:

Triple the amount of damages which the government sustained because of the act of that person

14

Civil penalties with false claims act:

$10,781-21,563 for each false claim

15

Stark 2 Law:

Intent was to prevent physician ownership of PT/OT clinics, DME companies, oxygen suppliers, and hospital inpatient or outpatient services
Intent to prevent referral for profit

16

Stark 2 Law exceptions:

Physicians can own PT and OT clinics as long as those clinics are within the physician clinic and the physician bills those services as “incident to” his/her own
They must be performed by a PT, OT, or SLP
PTAs cannot work directly for a physician and bill Medicare

17

Malfeasance

doing something stupid that one is not supposed to do (e.g., practice outside the practice act)

18

Misfeasance

doing something stupid (e.g., ultrasound on the temple)

19

Nonfeasance

should have taken action but did not (e.g., did not refer to emergency room when necessary)

20

Gross negligence

intentional or reckless omission
Intentional tort

21

4 elements of negligence

Duty of Care
Breach of Duty of Care
Injury
Causation/Proximate Cause

22

Duty of Care

Legal relationship between the parties which imposes an obligation of care, performance, or observance

23

Breach of Duty of Care:

Is determined by the jury - did the defendant (provider) fail to meet his/her duty?

24

Injury

Loss of income
Medical expenses
Loss of reputation
Pain and suffering

25

Causation/Proximate Cause

Plaintiff must prove by a preponderance of the evidence that, absent the defendant’s negligent act, the plaintiff would not have been injured

26

Malpractice:

doing something wrong when the practitioner should have known how to do it correctly

27

What can be used to establish standard of care?

community standards
national standards (guide to practice)
expert witness opinion

28

Strict Liability:

Seller is liable for any and all defective or hazardous products or services which unduly threaten a consumer’s safety, regardless of fault
Applies even if the seller has exercised all possible care in the preparation and sale of his/her product/service

29

Respondeat Superior

The master is responsible for the actions of the servant”
Hospital/nursing home/clinic is held vicariously liable for torts committed within the scope of employment of their employees

30

Imputed Knowledge

Doctrine of respondeat superior attaches liability to the organization regardless of whether the employer has actual knowledge of the specific act