2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and AbuseVerifying that the patient’s name, address,telephone, and date of birth match theidentification providedMaking copies to retain in the patient’s fileincluding but not limited to health planinsurance ID cards, Medicaid cards, anddriver’s licensesAsking the parent or adult accompanying aminor child to the appointment to provide hisor her photo identification and making copiesand retaining all the adult’s forms ofidentification provided in the minor child’smedical record.Federal Register (FR) and the Code of FederalRegulations (CFR)Published by the office of the Federal Register,National Archives and Records Administration, theFR is the official daily publication for rules,proposed rules, and notices of federal agenciesand organizations, as well as executive orders andother presidential documents. It is updated daily by6 a.m. and is published Monday through Friday,excluding federal holidays.The CFR is the codification of the general andpermanent rules published in the FR by theexecutive departments and agencies of the federalgovernment. It is divided into 50 titles that representbroad areas subject to federal regulation. Eachvolume of the CFR is updated once each calendaryear and is issued on a quarterly basis.Government InitiativesThe federal agencies responsible for oversight arethe Department of Health and Human ServicesOffice of Inspector General (DHHS OIG),Department of Justice, and the CMS. Because ofthe identified risks, CMS is responding with intenseoversight and increased funding for the DHHS OIG.Included in this oversight are additional fraud andabuse laws, audits, and investigations, includingmore than 140 assistant US attorneys trained onhealth care fraud.It is important for a provider to review and monitoractivities to determine that its practice is free frompotential fraud, waste, and abuse. Often, if leftunchecked, waste and abuse can become fraud.Federal and State False Claims ActsFederal False Claims ActThe Federal False Claims Act covers fraudinvolving any federally funded contract or program,with the exception of tax fraud.Under the Federal False Claims Act, those whoknowingly submit, or cause another person or entityto submit, false claims for payment of governmentfunds areLiable for three times the damages sufferedby the governmentCivil penalties of $5,500 to $11,000 per falseclaimTrial costsExclusion from Medicare and MedicaidPotential for criminal prosecutionFor example, a false $100 claim submitted forpayment with government funds would result in thefollowing penalties:15-72014 Practitioner and Provider Manual - Ver. 3