2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuseservices to federal and state programbeneficiaries.”You may not employ any individual who is listed asbeing excluded or debarred, so it is important tocheck the listings before hiring.Not only will you not receive payment for servicesfurnished by an excluded person but you will alsoface a fine of $10,000 for EACH item or serviceplus three times the amount of actual damages.This is another very good reason to check thelistings on a regular basis.Presbyterian requires that all providers review all oftheir employees and contractors or vendors againstthe GSA and OIG lists at least twice each year.Providers should retain written or hard-copy proofthat this activity has been completed and isaccessible during an audit. In addition, providersshould create a policy and procedure identifying thetimeline for completion, the format, and thehandling of employees identified as excluded.Fraud, Waste, and Abuse PreventionThe OIG has a recommended compliance plan forindividual providers and small groups that can befound at their website at http://oig.hhs.gov/. Whilethis program is a voluntary program, we highlyrecommend providers adopt their own complianceprogram, which should include the following sixelements identified by OIG:Implement written policies and proceduresConduct effective training and educationDevelop effective lines of communicationConduct internal monitoring and auditingEnforce standards through well-publicizeddisciplinary guidelinesImplement corrective actionRecoveries of Centennial Care Overpaymentsand FraudIdentification Process for OverpaymentsProviders are required to report overpayments toPresbyterian Centennial Care by the later ofThe date which is 60 calendar days after thedate on which the overpayment was identified;orThe date any corresponding cost report isdue, if applicable.A provider has identified an overpayment if theprovider has actual knowledge of the existence ofan overpayment or acts in reckless disregard orwith deliberate indifference of the overpayment. Anoverpayment shall be deemed to have been“identified” by a provider when the providerReviews billing or payment records and learnsthat it incorrectly coded certain services orclaimed incorrect quantities of services,resulting in increased reimbursementLearns that a patient death occurred beforethe service date on which a claim that hasbeen submitted for paymentLearns that services were provided by anunlicensed or excluded individual on its behalfPerforms an internal audit and discovers thatan overpayment existsIs informed by a government agency of anaudit that discovered a potential overpayment15-122014 Practitioner and Provider Manual - Ver. 3