Fraud & Abuse Prevention Flashcards

What is healthcare fraud?

Answer: Knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program

Healthcare fraud involves intentional deception or misrepresentation for unauthorized benefit, including billing for services not rendered, upcoding, unbundling, kickbacks, and falsifying records.

What is upcoding in healthcare billing?

Answer: Billing for a more expensive service or procedure than what was actually provided

Upcoding occurs when a provider bills for a higher-level (more expensive) service than was actually delivered, such as billing a complex office visit when only a routine visit occurred, to receive higher reimbursement.

What is the OIG Exclusion List?

Answer: A database of individuals and entities excluded from participation in federal healthcare programs due to fraud, abuse, or other violations

The OIG maintains the List of Excluded Individuals/Entities (LEIE). Healthcare organizations must check this list before hiring or contracting to ensure they do not employ or do business with excluded parties.

What is the difference between fraud, waste, and abuse in healthcare?

Answer: Fraud involves intentional deception; waste involves overutilization without intent to deceive; abuse involves practices inconsistent with accepted standards

Fraud requires intentional misrepresentation. Waste involves overuse of resources (unnecessary tests, inefficient practices) without intent to defraud. Abuse falls between, involving practices that are inconsistent with standards but may lack fraudulent intent.

What is a compliance hotline and why is it important?

Answer: A confidential reporting mechanism allowing employees and others to report suspected compliance violations without fear of retaliation

Compliance hotlines provide anonymous or confidential channels for reporting suspected fraud, waste, abuse, or other violations. Effective hotlines include non-retaliation protections and are essential for early detection of issues.

What is the Foreign Corrupt Practices Act (FCPA) and how does it relate to healthcare?

Answer: A US law prohibiting bribing foreign government officials, applicable when healthcare companies interact with government-owned hospitals or healthcare systems abroad

The FCPA prohibits US companies from paying bribes to foreign officials. In healthcare, this applies to interactions with government-owned hospitals, physicians employed by government health systems, and regulatory officials in other countries.