What is the purpose of healthcare fraud and abuse laws?

What is the purpose of healthcare fraud and abuse laws?

These laws are intended to prevent conflicts of interest between provider financial incentives and best patient care practices. Federal “fraud and abuse” law is actually a compilation of several laws, including the Federal Anti-Kickback Statute, the Stark Law, and the False Claims Act.

Why do you think that healthcare fraud and abuse is such a significant problem?

Health care fraud is a serious problem affecting every patient and consumer. As health care costs rise, so will the costs associated with these schemes. Consumers then will endure rising insurance premiums and out-of-pocket expenses.

What is fraud and abuse in the healthcare industry?

Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit. …

What is the definition of fraud waste and abuse?

Fraud includes false representation of fact, making false statements, or by concealment of information. Waste is defined as the thoughtless or careless expenditure, mismanagement, or abuse of resources to the detriment (or potential detriment) of the U.S. government.

What are fraud and abuse laws?

The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL).

Is fraud waste and abuse training mandatory?

All employees of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs) (collectively referred to in this course as “Sponsors”) must receive training for preventing, detecting, and correcting FWA. FWA training must occur within 90 days of initial hire and at least annually thereafter.

What should you do once fraud waste or abuse is detected?

Once fraud, waste, or abuse has been detected it must be promptly corrected. Correcting the problem saves the government money and ensures you are in compliance with CMS’ requirements.

What happens after non compliance is detected?

What Happens After Non-Compliance Is Detected? After non-compliance is detected, it must be investigated immediately and corrected promptly. No recurrence of the same non-compliance; • Ongoing compliance with CMS requirements; • Efficient and effective internal controls; and • Enrollees are protected.

What are some of the penalties for violating fraud waste and abuse FWA laws select the best answer?

Laws and regulations exist that prohibit FWA. Penalties for violating these laws may include: Civil Monetary Penalties; • Civil prosecution; • Criminal conviction/fines; • Exclusion from participation in all Federal health care programs; • Imprisonment; or • Loss of provider license.

What are some penalties for violating FWA?

Penalties include fines up to $25,000, imprisonment for up to 5 years and exclusion from Federal Health Care Programs (e.g., Medicaid & Medicare). *Remuneration is defined as the transfer of anything of value, directly or indirectly, overtly or covertly in cash or in kind, including kickbacks, bribes or rebates.

How can you prevent fraud waste and abuse?

Simple tips that may help you prevent fraud, waste and abuse includes:

1. Review your Explanation of Benefits to ensure accurate dates of services, name of providers, and types of services reported.
2. Protect your insurance card and personal information at all times.
3. Count your pills each time that you pick up a prescription.

Should FWA be corrected when it is detected?

errors? How Do I Correct Fraud, Waste, and Abuse?  Once FWA has been detected, it must be corrected.

Is unknowingly misusing codes on a claim?

Unknowingly misusing codes on a claim, such as upcoding or unbundling codes. There are differences among fraud, waste and abuse. One of the primary differences is intent and knowledge. Fraud requires intent to obtain payment and the knowledge that the actions are wrong.

What is FWA training?

General Compliance And Fraud, Waste And Abuse (FWA) Training.

Which are the ways to report potential FWA?

There are several ways to contact the Hotline:

1. Toll-free phone: 1-800-HHS-TIPS (1-800-447-8477), 8:00 am – 5:30 pm, Eastern Time, Monday-Friday.
2. Fax: 1-800-223-8164 (10 pages or less, please)
3. TTY: 1-800-377-4950.
4. Mail: HHS TIPS Hotline. P.O. Box 23489. Washington, DC 20026. (Note: please do not send any original documents)

What is the definition of a major section a violation?

Related Definitions Major violation means a violation of this part that may pose an imminent health hazard and warrants immediate closure or other corrective action.

What does correcting non compliance do?

Correcting non-compliance… Protects enrollees, avoids recurrence of the same non-compliance, and promotes efficiency.

What are FWA laws?

The federal False Claims Act (FCA) is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare (as well as Medicare Advantage [MA]) and Medicaid programs.

What are the consequences of non-compliance?

Financial Penalties – Failing to adhere to statutory compliance will lead to imposition of heavy fines and indirect losses to organizations. 4. Imprisonment – Severe cases of non-compliance may result in imprisonment of the organization’s CEO/Directors/Board members. 5.

What five 5 factors must a compliance plan include?

Does Your Compliance Program Contain the 5 Essential Elements?

• Leadership.
• Risk Assessment.
• Standards and Controls.
• Training and Communications.
• Oversight.