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A Roadmap for
New Physicians
AvoidingMedicare and
Medicaid Fraud
and Abuse
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Office of Inspector General
U.S. Department of Health & Human Services
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Health care fraud
is a serious problem
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Fraud includes obtaining a benefit
through intentionalmisrepresentation or concealment of
material facts
Waste includes incurringunnecessary costs as a result of
deficient management, practices, or
controls
Abuse includes excessively orimproperly using government
resources
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Physicians
ensure
qualitymedical
care
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False Claims
Act
Prohibits the
submission of false
or fraudulent claims
to the Government
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DeliberateDeliberate
ignoranceignorance
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Incentivestoreportfraud
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Anti-KickbackAnti-Kickback
StatuteStatute
Prohibits asking for or receiving anything
of value in exchange for referrals of
Federal health care program business
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Anti-Kickback StatuteAnti-Kickback Statute
Prohibited kickbacks include:
Cash for referrals
Free rent for medical offices
Excessive compensation for
medical directorships
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KickbacksKickbacks
can leadcan leadto:to:
Overutilization
Increased costs
Corruption of medical decisionmaking
Patient steering
Unfair competition
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FinesFinesPrisonPrison
TimeTime
Program
Penalties for
Kickbacks
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Waiving copayments
routinely
Waiving copayments on a
case by case basis for
financially needy
Providing free or discounted
services to uninsured patients
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Physician Self-ReferralPhysician Self-Referral
StatuteStatute
Limits physician referralswhen you have a financial
relationship with the entity
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ConsequenceConsequence
ssof violatingof violating
thethe
PhysicianPhysicianSelf-ReferralSelf-Referral
Statute:Statute:
Payment denial
Monetarypenalties
Exclusion
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Avoid violating the Anti-Kickback Statute and
Physician Self-Referral Statute
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Exclusion fromExclusion from
Medicare and MedicaidMedicare and Medicaid
Mandatory exclusionsMandatory exclusions
Permissive exclusionsPermissive exclusions
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CivilCivil
MonetaryMonetary
PenaltiesPenalties
LawLaw
Penalties range from
$10,000 to $50,000
per violation
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Common
PhysicianRelationship
s
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PayersPayers
Physicians/ProvidePhysicians/Provide
rsrs VendorsVendors
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Anti-fraud laws
protect
Medicare andMedicaid
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Fraudulent
billings result instiff penalties
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Accurate coding and billing are
important
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If you do not
know
how to code a
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Accurate medical
records are
critical
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Good
documentation
helps ensurequality patient
care
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Participating PhysiciansParticipating Physicians
May not
overcharge
Medicare
beneficiaries
May not sell thesame service
twice
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Non-
Participating
Physicians Bill directly to
patients
Patients
reimbursed byMedicare
It is illegal to
charge more
E i
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Exercise
caution
whencharging
extra fees
F t B iF t B i
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Future BusinessFuture Business
RelationshipsRelationshipsColleaguesColleagues
HospitalsHospitals
Nursing HomesNursing Homes
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Admit patients to the hospitalAdmit patients to the hospital
that best serves theirthat best serves their
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StayStay
Alert!Alert!
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RecruitmeRecruitment offersnt offers
can crosscan crossthe linethe line
Hire
me!
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MedicalMedicaldirectorsdirectors
shouldshould
exerciseexercise
substantivesubstantive
responsibilityresponsibility
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Interactions withInteractions with
companiescompanies
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It is illegal toIt is illegal to
sellsell S ti iScrutinize
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ScrutinizeScrutinize
promotionapromotiona
l speakingl speakingoror
consultingconsulting
opportunitiopportunitieses
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-
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Gift reporting
requirements
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ComplianceCompliance
programs keepprograms keep
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What todo when
ou
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