Medicare Fraud and Abuse: Summary and Analysis of Reforms in the Health Insurance Portability and Accountability Act of 1996 and the Balanced Budget Act of 1997
The Office, 1997 - Health insurance - 45 pages
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Accounting action activities adjusters adverse Allows amount annual applicable audit Authorizes basis beneficiaries benefit billing carrier Civil Monetary Penalties claims competitive Congress should consider contract contractors convicted costs criminal demonstration Department determination directly Documentation effect Eliminates enrollment enter entity equipment establish exclusion Extends facility false federal health Fee-for-Service fines fiscal Fraud and Abuse Fund HCFA health care fraud Health Care Offenses health care programs HHS Secretary HIPAA HMOs home health agencies hospital identified individual Inspector Insurance items and services managed managed care Medicaid Medicare program Medicare+Choice organizations monitoring nursing offer Office paid participation payment safeguard payments Recommendation percent performance period persons physical therapy physician policies practitioner Pricing procedures Provides rates Recommendation records reduce refuse Related report related to health Relevant legislation Requires sanctions standards statement status substantial supplier Table utilization violation waste
Page 12 - ... (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program...
Page 12 - ... health care benefit program. "(b) As used in this title, the term 'health care benefit program' means any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual, and includes any individual or entity who is providing a medical benefit, item, or service for which payment may be made under the plan or contract.".
Page 19 - ... has failed substantially to carry out the contract or is carrying out the contract in a manner inconsistent with the efficient and effective administration of the insurance program established by this part.
Page 19 - Secretary first provides the organization with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies...
Page 11 - Secretary shall provide for the annual auditing of the financial records (including data relating to medicare utilization, costs, and computation of the adjusted community rate) of at least one-third of the Medicare+Choice organizations offering Medicare+Choice plans under this part.
Page 10 - HHS with the employer identification number ("EIN") of each disclosing entity, each person with an ownership or control interest, and any subcontractor in which the entity has a direct or indirect 5 percent or more ownership interest.
Page 16 - D-3 (A)(i) who has a direct or indirect ownership or control interest of 5 percent or more in the entity or...
Page 38 - ... any practice that could reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by section 1903(m) of the Act) by eligible individuals whose medical conditions or histories indicate a need for substantial future medical services.
Page 8 - Secretary shall provide information via a toll-free telephone number on the programs under this title. (c) The notice provided under subsection (a) shall include — (1) a statement which indicates that because errors do occur and because medicare fraud, waste, and abuse is a significant problem, beneficiaries should carefully check any explanation of benefits or itemized statement furnished pursuant to section 1806 for accuracy and report any errors or questionable charges by calling the toll-free...