Health 3350 Exam #3 Study guide CH 16 – Flashcards

Intentional act of deception

Improper acts that are unintentional but inconsistent with standard practices, things such as false claims, duplicate billing etc.

Department of Health and Human Services, congress gave it power to investigate and enforce authority needed to deal with fraud and abuse violations

Made it a felony for a healthcare provider or beneficiary to possess knowledge of the occurrence of any even affecting any individual's initial or continued right to any such benefit or payment Violation is a felony and may include up to 5 years in prison and/or fines up to $25,000

MSE, a medical screening exam be given to any patient who presents to a provider of emergent of urgent care

They prohibit physicians from referring their patients to providers in which they have financial interest

is for laboratory services

was adopted for other ancillary services such as paying a physician for a referral

They impose criminal liabilities for the knowing and willful payment, solicitation, or receipt of remuneration in return for referring a person for, or for in return of purchasing, leasing, ordering of items or services reimbursable by the federal healthcare program. They are important because they get rid of the intent to refer patients when the physician does not have only the patients' interest in mind

Operation Restore Trust, started in 1995 to counter charges about fraud and abuse. ORT includes all 50 states

1- Written policies and standards of conduct 2- Designation of a compliance officer 3- Training & evaluation 4- Effective lines of communication 5- Enforcement procedures 6- Procedures for effective monitoring and auditing 7- Procedures for corrective action

the primary civil remedy by the federal gov't for fraudulent or improper healthcare claims. Removed the requirement that their be specific intent to defraud the federal gov't. Gov't need only to show that the claim submitted is false.

It is under the false claim act, it allows a person not in the gov't to bring a suit of past or present fraud on the gov't behalf