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Preventing Fraud, Abuse And Waste – Q&A
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Preventing Fraud, Abuse And Waste – Q&ANational Academy of Medicine has reported that approximately _________ per
year has been lost due to fraud, abuse, and waste ✔️Ans - $756 billion
Fraud, abuse, and waste is a major concern because it results in: ✔️Ans - -
overutilization of services
-increased costs for payers
-corruption of medical decision making
-unfair competition
-harm to patient
The government has found that for every $1.00 spent on fighting fraud, abuse,
and waste, ______ is returned. ✔️Ans - $8.10
fraud definition ✔️Ans - intentional deception or misrepresentation that a
person makes to gain a benefit to which they are not entitled
knowingly billing for services not furnished is an example of ✔️Ans - fraud
Knowingly altering claim forms to receive more payment is an example of
✔️Ans - fraud
Falsifying documentation to receive payment for which you are not entitled is
an example of ✔️Ans - fraud
Abuse definition ✔️Ans - payment for items or services that the provider
is not entitled to and for which the provider has not intentionally
misrepresented facts to obtain payment
Billing services that are not medically necessary is an example of ✔️Ans -
abuse
Billing for services that do not meet professional standards of practice is an
example of ✔️Ans - abuse
, Unbundling services and billing for them; for example billing separately for
electrodes, which are considered part of the payment for electrical stimulation
is an example of ✔️Ans - abuse
Waste definition ✔️Ans - incurring unnecessary costs due to deficient
management practices, systems, or controls
Duplication of tests and services that were already provided is an example of
✔️Ans - waste
Spending on services when there are less costly alternatives that would result
in the same outcome is an example of ✔️Ans - waste
Ordering unnecessary tests to guard against liability is an example of ✔️Ans
- waste
Failures of care coordination that result in hospital readmissions or
complications is an example of ✔️Ans - waste
False Claims Act ✔️Ans - Prohibits the knowing submission of false claims
or use a false record to obtain payment from the Medicare or Medicaid
programs
Penalty for violation of the false claims act ✔️Ans - as high as $22,000 per
claim, plus 3 times the damages sustained by the government - license
sanctions and exclusion from federal program
Under the false claims act, whistleblowers can receive up to _____ of recovery
✔️Ans - 30%
Under the false claims act, whistleblowers can include ✔️Ans - ex-
business partners, staff, competitors, pts
The following is an example of _________: an employee of a physical therapy
service signed his name on patient medical records, such as progress reports
and daily notes, as the provider of the therapy services. However, he was not
licensed, trained, or in any way qualified to provide physical therapy to
patients ✔️Ans - fraud
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