WHAT IS A FALSE CLAIM? ARE MISTAKES AND ERRORS CONSIDERED TO BE FRAUDULENT BEHAVIOR? WHAT IS THE PURPOSE OF A COMPLIANCE PROGRAM?

WHAT IS A FALSE CLAIM? ARE MISTAKES AND ERRORS CONSIDERED TO BE FRAUDULENT BEHAVIOR? WHAT IS THE PURPOSE OF A COMPLIANCE PROGRAM?

Review below on Title II and Healthcare Fraud and Abuse information and answer the following questions:

What is a false claim?
Are mistakes and errors considered to be fraudulent behavior?
What is the purpose of a Compliance Program?
There are seven steps to the compliance program. Think about your role in insurance billing. Describe the steps where you will be able to have the greatest impact to help avoid creating erroneous and fraudulent claims. What are some best practices you could implement within these steps to ensure you are adhering to Title II?
Require in 150 words APA format, reference search via website.

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HIPAA Title II”Preventing Health Care Fraud and Abuse

HIPAA defines fraud as œan intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment. The attempt itself is considered fraud, regardless of whether it is successful. Abuse œinvolves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The difference between fraud and abuse (Table 5-2) is the individual’s intent; however, both have the same impact in that they steal valuable resources from the healthcare industry.

When a Medicare provider commits fraud, an investigation is conducted by the Department of Health and Human Services (DHHS) Office of the Inspector General (OIG). The OIG Office of Investigations prepares the case for referral to the Department of Justice for criminal and/or civil prosecution. A person found guilty of Medicare fraud faces criminal, civil, and/or administrative sanction penalties, including:

Civil penalties of $20,000 per false claim plus triple damages under the False Claims Act. (The provider pays an amount equal to three times the claim submitted, in addition to the civil penalties fine.)
Criminal fines and/or imprisonment of up to 10 years if convicted of the crime of healthcare fraud as outlined in HIPAA or, for violations of the Medicare/Medicaid Anti-Kickback Statute, imprisonment of up to 10 years and/or a criminal penalty fine of up to $100,000.
Administrative sanctions, including up to a $20,000 civil monetary penalty per line item on a false claim, assessments of up to triple the amount falsely claimed, and/or exclusion from participation in Medicare and state healthcare programs.
In addition to these penalties, those who commit healthcare fraud can also be tried for mail and wire fraud.

TABLE 5-2 Fraud and abuse examples and possible outcomes

EXAMPLES OF FRAUD POSSIBLE OUTCOMES OF FRAUD
·        ¢ Accepting or soliciting bribes, kickbacks, and/or rebates

·        ¢ Altering claims to increase reimbursement

·        ¢ Billing for services or supplies not provided

·        ¢ Misrepresenting codes to justify payment (e.g., upcoding)

·        ¢ Entering a health insurance identification number other than the patient’s to ensure reimbursement

·        ¢ Falsifying certificates of medical necessity, plans of treatment, and/or patient records to justify payment

·        ¢ Administrative sanctions

·        ¢ Civil monetary penalties

·        ¢ Exclusion from the health program (e.g., Medicare)

·        ¢ Referral to the Office of Inspector General

o   ¢ Exclusion from Medicare program

o   ¢ Sanctions and civil monetary penalties

o   ¢ Criminal penalties (e.g., fines, incarceration, loss of license to practice, restitution, seizure of assets)

EXAMPLES OF ABUSE POSSIBLE OUTCOME OF ABUSE
·        ¢ Billing

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