Health fraud

quickster2008's version from 2015-11-16 13:21


Question Answer
meant to protect the public from incompetent physicians by allowing those physicians on peer review committees to communicate in an open and honest environment and thus weed out incompetent physicians, without the specter of a retaliatory lawsuit by the reviewed physicianHCQIA Health Care Quality Improvement Act of 1986
if any individual comes to the ED and a request is made for examination or treatment for a medical condition, the hospital must provide an MSE to verify there is an emergency medical condition.EMTALA: Emergency Medical Treatment and Labor Act:
encourages State Licensing boards, hospitals and entities and professional societies to ID and discipline those who engage in unprofessional behavior;Title IV of Public Law:
to encourage peer review, immunity from liability is given, but still can sued by individualCivil Liability Protection
doctors may request info on their colleagues exception is that ? MUST query on doctors every 2 yrs or when hiring or granting more privilegeshospitals
restrict the movement of incompetent health care providers from state to state without disclosure or discovery, basically if like a sex offender account only if you have malpractice suitNPDB: National Practitioner Data Bank
Civil Monetary Penalty Lawfines doctors who try to reinburse for something they didn't do
EMTALA: Emergency Medical Treatment and Labor Act:public has access to emergency services regardless of pay
law that imposes liability on person and companies who defraud gov programs, reimbursing for wrong proceduresfalse claims act
Prove False claims by looking atICD(diagnosis) and CPT(procedures) codes
billing for more expensive procedures or more severe illnessupcoding
private individual with knowledge of past or present fraud committed against the federal government to bring suit on its behalf.Qui Tam (whistleblower suits)
Crime to offer, to pay, to solicit, to receive remuneration (anything of value) for referral or serviceAnti-Kickback Statute
prohibits physician referrals of designated health services ("DHS") for Medicare and Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity. (can't refer to your own product)Stark Law (Physician Self-Referral Law)
is the stark law a criminal law?CIVIL law
T or F it is legal to provide free or discounted services to uninsured people.F
Stark lawreferring pts to specific medicare or medicaid things so you can get a reburstment
Excluded physicians may not bill directly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice.exclusion statue doctors who are excluded from participation in all Federal health care programs bc of criminal offenses