CPMA Certification Study Guide (Fall) Chapter 1 Graded A+

How does CMS define fraud? - ANS Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program. How does CMS define abuse? - ANS An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Example of Fraud - ANS Billing for services and/or supplies that you know were not furnished or provided Altering claim forms and/or receipts to receive a higher payment amount Billing for services at a higher level than provided or necessary Misrepresenting the diagnosis to justify payment CMS Examples of Abuse - ANS Misusing codes on a claim Charging excessively for services or supplies Billing for services that were not medically necessary Failure to maintain adequate medical or financial records Improper billing practices Billing Medicare patients a higher fee schedule than non-Medicare patients Federal False Claims Act - ANS A law that allows for individuals to bring civil actions on behalf of the U.S. government for false claims made to the federal government, under a provision of the law called qui tam (from Latin meaning "to bring an action for the king and for oneself"). Examples of fraud or misconduct subject to the False Claims Act include: - ANS Falsifying a medical chart notation Submitting claims for services not performed, not requested, or unnecessary Submitting claims for expired drugs Upcoding and/or unbundling services Submitting claims for physician services performed by a non-physician provider without regard to Incident-to guidelines The FCA allows for reduced penalties (mitigation) if the person committing the violation self-discloses, and if: - ANS * the person responsible furnishes officials of the U.S. responsible for investigating false claims violations with all information known to such person about the violation within 30 days after the date on which the defendant first obtained the information * such person fully cooperates with the investigation of such violation * at the time such person furnishes the information about the violation, no criminal prosecution, civil action, or administrative action has commenced under this title with respect to such violation, and the person