AHIP 2023 MEDICARE FRAUD, WASTE, & ABUSE WITH VERIFIED CORRECT ANSWERS

False Claims Act (FCA) Federal law prohibits submitting a fraudulent claim or making a false statement or representation in connection with a claim. Penalty up to three times Governments Damages PLUS a penalty. Healthcare Fraud Statute Whoever knowingly or willfully executes or attempts to execute a scheme or artifice to defraud any Health Care benefits program shall be fined or imprisoned for not more than ten years or both. Criminal Healthcare Fraud - Knowingly making a false claim the penalties are: Fines up to 250,000 Imprisonment up to 20 years. or possibly a life sentence if the criminal activity results in death. Anti-Kickback Statute penalties are: Fines up to 25,000 and/or imprisonment up to 5 years. Stark Statue (Physician Self Referral Law) pertains to: Referral to others who may be family members which have an ownership investment interest or compensation arrangement. Civil Monetary Penalties Law (CMPL) A law passed by the Federal Government to prosecute cases of Medicaid fraud. Exclusion LEIE An exclusion of payment for Federally funded healthcare programs by the O.I.G. office. HIPPA Health Insurance Privacy and Portability Act Safeguards deter unauthorized access to protected healthcare information. Violations can result in Civil monetary penalties and in some cases Criminal penalties as well. Fraud, Waste and Abuse primary differences Intent and Knowledge Fraud requires Intent to obtain payment AND the knowledge that it is wrong. Waste and Abuse may involve improper payment but NOT the same knowledge and intent. Fraud, Waste, and Abuse Penalties may include: Civil Monetary Penalties Civil Prosecution Criminal Conviction, Fines or BOTH Exclusion from Federal Healthcare program participation. Imprisonment. Responsibility Duties 1, 2, 3 First: Comply with all applicable rules and regulations. Second: Report any Compliance concerns or violations. Third: Follow your employers ethical code of conduct for rules of behavior. Indicators of Fraud, Waste and Abuse Do records look altered or possibly forged? Does medical history support services requested? Have numerous identical prescriptions been filled by different doctors? Is the person receiving the benefit the actual person? Identity theft? Is a prescription appropriate based on other prescriptions being requested? Medically necessary? Unusual high dosages? Services being billed that were not rendered. Unnecessary procedures being requested. Is there a VALID National Provider Identification Number listed on the prescription? Is diagnosis supported in medical record?