Fraud and Abuse - Unit 3

These flashcards cover essential vocabulary terms related to fraud and abuse in healthcare, including definitions and implications of various laws and regulations.

Fraud

The intentional act of deceiving.

Abuse

An unintentional act that is inconsistent with standard practice.

Up-coding

Purposefully charging more than what is allowable or what procedures were performed.

Under-coding

Charging less than what should be charged for a procedure.

False Claims Act

A federal law imposing liability on persons and companies that defraud governmental programs.

RAC (Recovery Audit Contractors)

A program created to identify and recover improper Medicare payments.

HEAT (Health Care Fraud Prevention and Enforcement Action Team)

An initiative created in 2009 to combat health care fraud.

Criminal Disclosure Provision

A law making it a felony for healthcare providers to conceal information about fraudulent claims.

Physician Self-Referral Laws

Laws aimed at preventing conflicts of interest in Medicare patient referrals.

Stark I

The law that applies to physicians referring patients for laboratory services where they have a financial interest.

Stark II

Expanded regulation that applies Stark I violations to all ancillary services.

Anti-Kickback Regulations

Laws preventing payment as an inducement to refer Medicare patients for services.

Safe Harbor Regulations

Provisions allowing certain business practices to be immune from Anti-Kickback sanctions.

Internal Control

Mechanisms to ensure reliable financial reporting and compliance with regulations.

Control Environment

The foundation of an internal control system, setting the organizational tone.

Risk Assessment

The identification and analysis of relevant risks to organizational objectives.

Control Activities

Policies and procedures put in place to ensure management directives are followed.

Information and Communication

The process of exchanging information to enable responsible action within an organization.

Monitoring

The ongoing process of assessing the quality of internal control over time.