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At least 127 records · Page 7Linked to original sources
PubMed1988

Medicare fraud and abuse: implications for physicians.

Since the inception of the Prospective Payment System, the physician fee freeze, and other cost-cutting measures, physicians have been approached with many income-generating opportunities relating to their practices. Unfortunately, many of these opportunities also present potential criminal and civil liability under federal Medicare anti-fraud and abuse provisions. The recent passage of the Medicare and Medicaid Program Patient Protection Act of 1987 has updated federal anti-fraud and abuse laws and expanded the sanctions which may be imposed on physicians. This article describes the types of activities prohibited by federal laws and discusses the operation of these laws in light of common joint venture, incentive, and contract arrangements frequently seen in medical practice.

Crime↗
PubMed1989

Mooring in safe harbors. Proposed rules set out what's legal, what's not under Medicare fraud and abuse laws.

The 1977 Fraud and Abuse Amendments, which prohibit business relationships that increase Medicare utilization, have created uncertainty among healthcare providers as to which commercial arrangements are legal and which are not. In response to this uncertainty, Congress enacted the Medicare and Medicaid Patient and Program Protection Act of 1987, which required the Department of Health and Human Services to develop regulations that would specify allowable practices. The regulations proposed Jan. 23, 1989, specify "safe harbors" from criminal and civil penalties in the following areas: sales of physician practices, rental agreements, investments by providers, and personal services and management contracts. In addition, the Fraud and Abuse Amendments exempted referrals arising out of a bona fide employment relationship, properly disclosed discounts, and group purchasing arrangements. The proposed regulations attempt to clarify these exemptions. Unfortunately, the proposals do little to calm a healthcare industry that is jumpy about which transactions are permitted and which are not. This is partly because the Internal Revenue Service, Health and Human Services, and the Department of Justice often issue conflicting pronouncements regarding prohibited business transactions by tax-exempt providers.

Contract Services↗
PubMedDate not supplied

Medical consultant key to dealing effectively with insurance fraud and abuse.

An unexpected, but everpresent, by-product of the development of the health care insurance industry is the tendency of those using the industry's services to "game" the system. While fraud and abuse in the claiming of insurance benefits are not the only or the most significant cause of steeply rising health care costs, they certainly contribute to the problem. Payers are advised to maintain a sharp eye for potential fraud and abuse and to observe some simple rules for detecting and eliminating them.

Consultants↗
PubMed1998

Avoiding pharmacy fraud through automation and audit.

Pharmacy data offer some of the most reliable and evaluative information in managed care today. As fraud constitutes up to 10% of our total health care expenditures, the author explains how monitoring the pharmacy network for fraud and abuse is an easy way of reclaiming some of these losses.

Electronic Data Processing↗
PubMed1999

Health care fraud enforcement in 1999.

In the current legal and political environment, it is apparent that health care providers will be under more scrutiny for fraud and abuse issues than ever before. Fortunately, some of the areas on which government enforcement personnel will be concentrating are known. This article will review the resources to be devoted to fighting health care fraud and discuss the specific areas to be targeted by enforcement officials.

Delivery of Health Care↗
PubMed1999

Securing insurance protection against fraud and abuse liability.

Healthcare organizations concerned about corporate compliance need to review securing appropriate insurance coverage as part of their corporate compliance program. Provider organizations often mistakenly expect that their directors and officers liability (D&O), malpractice, or standard errors and omissions (E&O) insurance policies will cover the cost of Medicare fraud and abuse fines. The insurance industry has developed a specific billing E&O insurance product to cover providers that run afoul of government fraud and abuse statutes.

Fees and Charges↗
PubMed1999

The role of the states in combating managed care fraud and abuse.

Professor Krause describes the weapons available to state regulators to address managed care fraud. Although many commentators have focused on recent federal anti-fraud efforts, Professor Krause argues that the states, through the use of a number of existing legal theories, have the most flexibility to combat fraudulent managed care practices. By using these targeted state-based efforts (in contrast to broader federal provisions), state regulators may be able to resolve problems more efficiently and with greater patient benefits.

Consumer Advocacy↗
PubMed1999

Public/private information sharing in healthcare fraud investigations.

Private insurers have good reason, both in their private interest and in the public interest, for pursuing and rooting out fraud in the healthcare system; moreover, they often have sophisticated data systems, substantial investigative information, and management expertise that can be useful to prosecutors. It makes sense, as a public policy matter, to undertake steps to encourage insurers to be aggressive in pursuing legitimate fraud cases, and to provide a framework for effective cooperation and information sharing with law enforcement. At the same time, prosecutors are responsible for enforcing equal justice under the law; thus, any such relationship must be handled in an appropriate manner, with safeguards to protect privacy and the reputation of investigative subjects. While the courts have not yet explored many of the relevant legal and factual issues in this area, the author surveys existing guidance under governing laws and policies applicable to state and federal prosecutors, and suggests techniques to prevent inappropriate communication or use of such information.

Confidentiality↗
PubMed1999

What home healthcare nurses should know about fraud and abuse.

Home care nurses provide a critical linh in all services provided by a home health agency. This article outlines basic information nurses can use to understand fraud and abuse regulations, see the importance of corporate compliance programs, and recognize the potential impact a focus on fraud and abuse has on their practice.

Community Health Nursing↗
PubMedDate not supplied

How to avoid fraud and abuse by following compliance guidelines.

Rules of the Health Care Financing Administration, United States Department of Health and Human Services, are reviewed as applied to fraud and abuse. The voluntary compliance guidelines that were released by the Office of the Inspector General in October, 2000 are also reviewed. The author demonstrates that the practicing physician can use these guidelines to enhance a medical practice and protect practitioners from accusations of fraud and abuse.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Using data mining to find fraud in HCFA health care claims.

Data mining can be/used to detect health care fraud and abuse through visualization of very large data sets to isolate new and unusual patterns of activity. Data mining has allowed better direction and use of health care fraud detection and investigative resources by recognizing and quantifying the underlying indicators of fraudulent claims, fraudulent providers, and fraudulent beneficiaries. A large amount of work must be performed prior to the actual data mining. These precursory tasks include: customer discussions, data extraction and cleaning, transformation of the database, and auditing (basic statistics and visualization of the information) of the data. This paper describes the tasks performed in support of a project for HCFA (Health Care Financing Administration).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Unexpected turn of events. After a five-year battle, an appeals court overturns the fraud convictions of two former Columbia/HCA executives.

For former Columbia/HCA executives Jay Jarrell and Robert Whiteside, the overturning of their 1999 fraud convictions was a get-out-of-jail-free card. A federal appeals court ruled that the government didn't prove its case against them and that the rules they were meant to follow were confusing. And if the government didn't prove its case here, what does this judgment mean for other fraud cases?

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2003

Quackery and fraud: understanding the ethical issues and responding.

A small number of dentists abuse their patients and the public trust in the profession by practicing quackery or fraudulent or questionable dentistry. Such practitioners can be classified as incompetent, as treating their patients as a means to personal fulfillment, as operating beyond their legal qualifications, or as being quacks, charlatans, or frauds. Ethical practice requires all five of these characteristics: informed consent, high benefit to risk ratio, competence, professional integrity, and reasoned scientific basis for care. Quacks and frauds place their own interests and judgment above those of their patients and the profession. Ethical dentists have obligations to act to protect their patients and the profession in their relationships with patients and with colleagues, as a profession in dealing with the public, and as a research community.

Clinical Competence↗
PubMed2004

Medicare fraud and abuse.

Medicare fraud and abuse affects the quality of services and the cost of health care. The Department of Health and Human Services is partnering with federal and local agencies to educate consumers to recognize and report suspected cases. In this brief we discuss the Senior Medicare Patrol Project and the roles of the federal agency organizations in preventing fraudulent activities in the Medicare system. We also profile the Ohio Seniors Fight Fraud Project.

Aged↗
PubMed1992

Is new OIG physician fraud alert precursor to enforcement action?

A recent fraud alert published by the OIG listing "suspect hospital incentive arrangements" in physician recruitment practices is compelling hospital executives to review their recruitment strategies. "What is new about this fraud alert," says an attorney, "is that the OIG has put them into one document as an indication of its enforcement priorities."

Fraud↗
PubMed1995

Concern over fraud causes Ontario to invest $90 million in new health cards.

In an attempt to stop fraudulent use of Ontario's health care system, the province will soon begin issuing health-insurance cards containing the holder's photo. It is not known exactly how much fraud costs the system, but the cost may exceed $100 million annually. Dr. John Carlisle, deputy registrar of the College of Physicians and Surgeons of Ontario, warns that the government must be prudent in designing a system for reporting suspected health-card fraud.

Fraud↗
PubMedDate not supplied

Nurses' and other experts' views of health care fraud and abuse.

This study examines the perceptions of a Florida panel of experts regarding the effectiveness and cost effectiveness of changes in law related to health care fraud and abuse. The panel was established as a task force under Florida health reform initiatives. The panel first defined fraud and abuse, then studied a variety of proposed initiatives, and finally rated each initiative as to its effectiveness and cost-effectiveness. Findings show significant perceptual differences between the nurses' perceptions and those of other panelists.

Attitude of Health Personnel↗