CMP Penalties - may range from up to $10,000 to $50,000 per violation, depending on the type of
violation and the entity. They may also include an assessment of up to 3x the amount claimed for each
item or service, or up to 3x the amount of remuneration offered, paid, solicited, or received. For
...
CDEO Chapter 3
CMP Penalties - may range from up to $10,000 to $50,000 per violation, depending on the type of
violation and the entity. They may also include an assessment of up to 3x the amount claimed for each
item or service, or up to 3x the amount of remuneration offered, paid, solicited, or received. For
example, for fraudulent claims, the OIG may seek a penalty of up to $10,000 for each item or service
improperly claimed, and an assessment of up to 3x the amount of the improperly claimed.
CMS Definition of Abuse - an action resulting in unnecessary costs to a federal healthcare program
either directly or indirectly
May 1995 Bill Clinton: 2 yr partnership of federal and state agencies, working together to protect the
healthcare trust funds through shared intelligence coordinated enforcement, intended to enhance
quality of care for program's beneficiaries.
Program is not called Senior Medicare Patrol SMP
They work to combat fraud and abuse.
SMP - Senior Medicare Patrol
OIG - Office of Inspector General
AoA - Administration on Aging
FCA - False Claims Act
CMPL - Civil Money Penalties Law
,CMS Definition of Fraud - knowingly making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from a federal healthcare program
CMS Examples of Fraud - Billing for Services/Supplies that you know were not furnished or
provided
Altering claim forms and/or receipts to receive a higher payment amount
Billing for services at a level higher than provided or necessary
Misrepresenting the diagnosis to justify payment
Making referrals to certain designated services that are prohibited
CMS Examples of Abuse - Misusing codes on claims
Charging excessively for service or supplies
Billing for services that were not medically necessary
Failure to maintain adequate medical or financial records
Improper billing practices
Billing Medicare patients a higher fee schedule than non-medicare patients
FCA - Federal
, False Claims Act
Lincoln Law - False Claims Act, enacted 1863 to combat fraud from suppliers of good to the Union
Army during the Civil War
In 1943 amendments made it more difficult to bring action forward.
In 1986 Congress enacted an overhaul that generated new fraud investigations and actions.
The Statute is in title 31, subtitle III, CH. 37, subchapter III, of the US code 31 U.S.C. 3729(a).1
Title 31 Statute's 7 Types of Conduct - that brings liability FCA
It states a person is liable who:
A) Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
B) Knowingly makes , uses, or causes to be made or used, a false record or statement material to a false
or fraudulent claim
Title 31 Statute's 7 Types of Conduct - C) Conspires to a violation of subparagraph (A), (B), (E), (F),
or (G);
D) Has posession, custody, or control of property or money used, or to be used, by the government and
knowingly delivers, or causes to be delivered , less than all of that money or property;
Title 31 Statute's 7 Types of Conduct - E) Is authorized to make or deliver a document certifying
receipt of property used, or to be used, by the government, and intending to defraud the government,
makes or delivers the receipt without completely knowing that the information on the receipt is true
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