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Intentional act of deception
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Improper acts that are unintentional but inconsistent with standard practice
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Common forms of fraud/abuse:
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Up-coding, kickbacks, false claims, duplicate billing
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Laws relating to fraud/abuse
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Operation restore trustRecover audit contractors (RAC)Health care fraud prevention & enforcement action team (HEAT)Safe Harbor
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False claims act (1863)
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Primary civil remedy by the federal gov't for fraudulent health care claims
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In 1986, the first major amendments were added to the FCA:
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Gov't needs to show that the claim submitted is false & was submitted knowingly
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How much money was recovered through violations of health care fraud of the qui tam provision of the FCA in 2003?
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Operation Restore Trust (ORT)
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Gave investigative & enforcement authority necessary to address health care fraud/abuse
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When was ORT expanded to include 12 more states? (Now includes all state)
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Tens of billions of dollars were lost to fraud/abuse in _______?
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How has ORT been proven a success?
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Billions of dollars have been restored to the program.
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ORT has been supplemented with the addition:
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Violations of The Social Security Act and the Criminal Disclosure Provision
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Felony, may include punishment of up to 5 years in prison and/or fines up to $25,0000
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The Emergency Medical Treatment and Active Labor Act (EMTALA)
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Prevent patient dumping, mandates MSE to be given,
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To avoid EMTALA violations, providers should:
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Ensure that all pt's are offered MSE & tx before they leave, refusal of tx should be documented
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Antitrust Issues
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Implemented to protect from the negative effects of monopoliesConsists of Sherman Act, Clayton Act, FTC
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Prohibits all conspiracies that restrain trade
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Federal Trade Commission
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Prohibits unfair methods of competition
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Stark 1- lab servicesStark - other ancillary services
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Stark Physician Self-Referral Laws
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Prohibit physicians from referring their pt's to providers they have a financial interest in
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Safe Harbor/Anti-Kickback Regulations
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Prevent conflicts of interest in patient referrals.
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Anti-kickback regulations exclude:
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Federal Employees Benefits Program
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New ASC safe harbor contains 4 categories:
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Surgeon ownedMulti-specialtySingle specialityHospital/physician owned
