Transcript Document

WELCOME TO
SEMINAR 4
RISKS TO THE MEDICAL OFFICE
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Fraud: An intentional deception or
misrepresentation made by an individual who
knows that the false information reported could
result in a benefit to himself/herself or another
person.
Abuse: An incident or practice not consistent
with sound medical, business, or fiscal practices,
such as providing medically unnecessary care or
care that does not meet the standards of care.
NOT abuse when service IS Necessary.
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The Fraud and Abuse Control Program was
established by the government under:
HR3103 Subtitle A
Example of fraud?
Altering claims, over-billing, Over- utilization.
NOT CREDIT BALANCES FOR PT.
The first fraud alert was issued in: 1988
Fraud alerts? Nursing home services, Waiver of
co-pays, Joint venture arrangements
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Under the Beneficiary Incentive Program,
beneficiaries receive at least which of the
following dollar amounts for reporting fraud?
$100
Is Your Practice Guilty of Fraud and Abuse?
Is the service/supply necessary?
Is the service/supply appropriate according to
professionally recognized standards?
Has a fair price been charged?
LEGISLATIONS AND ACTS
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In which year did antitrust laws begin to
affect health care? 1975- cannot ruin
another business etc
Medicare and Medicaid Patient and
Program Protection Act of 1987
http://www.netreach.net/~wmanning/fasum
m.htm
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The Patient Self-Determination Act came
into effect in which year? 1991
http://www.legalhelpmate.com/healthcare-directive-patient-act.aspx
Have to give pt notice of rights for end of
life choices, need someone listed as
contact. You can accept or refuse care.
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Which act provides for overtime worked?
Fair Labor Standards Act
Which act was designed to protect the
handicapped against discrimination?
Vocational Rehabilitation Act
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The Food and Drug
Administration is a
division of ? Public
Health Service
Which act protects
employees from
benefits
discrimination? Older
Workers Benefit
Protection Act.
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Preventing a Lawsuit
Maintain accurate and neat records
Have a risk management plan
Have good rapport with patients
Have prescription renewals policy in place
Have respect for patients and their families
Strive for good treatment outcomes
Provide patient services based on accepted
standards of care
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Law and abortion: name of PCP is not
required.
OIG = Office of Inspector General. They
don’t consider a Dr.’s relationship with a
collection agency as a risk.
hot line issues: most reported are: Conflict
of interest, theft, injustice from admin.
SOME MID TERM INFO NOT
COVERED
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Dr. visits require a code, like other
services. They all begin with 9929--. Go by
level of time spent, new Pt. etc.
The following is one of the key factors in
choosing an E&M code: Medical decision
making (Evaluation and Management)
The 1995 definition of a detailed
examination is: Extended exam of affected
body area and other symptomatic systems