2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuseis violated regardless of whether the physician orthe entity providing the designated health servicehas any intent to violate or even knows that thereferral is prohibited. Penalties include$15,000 fine per claim and possible exclusionPotential anti-kickback liability (if intentionalviolation)Beneficiary Inducement Civil Monetary PenaltyLawThe beneficiary inducement law prohibits providersfrom incentivizing a beneficiary who is enrolled in agovernment health care program to see a particularprovider because it could encourage theoverutilization of health care supplies and services.Violations of this law can result in substantialpenalties.Penalties includeFines up to $10,000 per violation plus trebledamagesPotential exclusion from participation ingovernment programsProgram Exclusion ListsThe Federal Exclusion Law allows the DHHS OIGto exclude individuals and organizations fromparticipating in Medicare, Medicaid, and othergovernment programs. Reasons for exclusioninclude violating fraud and abuse laws, licensingboard actions (such as suspended license),defaulting on federal student loans, and controlledsubstances violations, as well as other crimes.Providers and subcontractors who participate inMedicare and Medicaid programs are required toverify that their employees are not on the federalexclusion lists (meaning the individual is prohibitedfrom participating in Medicare- and Medicaidfundedservices).Physicians, non-physician practitioners, andemployees must not be identified on the DHHS OIGor General Services Administration (GSA) lists.Providers may log on to the following OIG/GSAwebsites listed to verify the eligibility of individuals:Department of Health and HumanServices/Office of Inspector General(DHHS/OIG), List of Excluded Individuals andEntitieshttps://oig.hhs.gov/exclusions/exclusions_list.aspGeneral Services Administration’s System forAward Management (GSA SAM)https:www.sam.gov/portal/public/SAM/Insurance companies (sponsors) do not pay fordrugs prescribed or other services provided by aprovider who is excluded by either the DHHS OIGor GSA. Additionally, excluded providers may notcontract with or perform services related to anygovernment contract including the FederalEmployee Benefit Program and Medicare orMedicaid.According to the OIG, pharmacies cannot bill for“services performed by, prescribed by, processedby or involved in any way in filling prescriptions” byindividuals who are excluded from federal and stateprograms to Medicare beneficiaries.The prohibition “also extends to payment foradministrative and management services notdirectly related to patient care, but that are anecessary component of providing items and15-112014 Practitioner and Provider Manual - Ver. 3