Examples of False claims
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, **A pharmacy consistently bills a MA plan for more pills than are actually
dispensed to the plan's enrollees.
**A physician knowingly submits claims for services never provided to
Medicare enrollees.
Who Commits Medicare FWA?
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1. Medicare beneficiaries
2. Physicians and other healthcare providers
3. Pharmacies, pharmacists, and pharmaceutical manufacturers and
wholesalers
4. Health plan employees
5. Insurance agents and brokers
6. parties who neither provide not receive healthcare (professional criminals,
including members of organized crime)
7. Combinations of the above working together in collusion.
Civil monetary penalties CMP's
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Penalties that may be imposed for a variety of conduct including Medicare
FWA. Different amts. of penalties and assessments may be authorized based
on the type of violation and can range as high as $50,000 per violation.
Example: Presenting a claim that a person knows or should know is for a
service that was NOT provided as claimed or is false and fraudulent.
, Legal Tools Against FWA (to Combat FWA)
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There are several legal tools that the government can employ in its fight
against FWA, including the following statutes:
1. Federal Civil False Claims Act
2. Anti-Kickback Statute
3. Physician Self-Referral Law (Stark Legislation)
4. Criminal Health care Fraud Statute
5. Criminal False Statements Act
6. HIPPA and HITECH Act
**Violations of these laws can result in non-payment of claims, imposition of
CIVIIL MONETARY PENALTIES, exclusions from the Medicare program,
imprisonment and criminal and civil liability.
FWA Related to Agents and Brokers
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--An agent offers Medicare beneficiaries cash or other impermissible
incentives to enroll in the Rx plan he represents.
--An agent offers beneficiaries money for names, address and phone
numbers of friends and acquaintances who are Medicare beneficiaries.
--An agent forges a beneficiary's signature on an enrollment form.
--An agent intentionally misrepresents a plan's costs or benefits for the
purpose of attaining enrollment, or convincing someone to enroll.
--An individual solicits MA enrollments and gather "initial premiums". She is
not really an agent and disappears with the money.
Give this one a try later!
, **A pharmacy consistently bills a MA plan for more pills than are actually
dispensed to the plan's enrollees.
**A physician knowingly submits claims for services never provided to
Medicare enrollees.
Who Commits Medicare FWA?
Give this one a try later!
1. Medicare beneficiaries
2. Physicians and other healthcare providers
3. Pharmacies, pharmacists, and pharmaceutical manufacturers and
wholesalers
4. Health plan employees
5. Insurance agents and brokers
6. parties who neither provide not receive healthcare (professional criminals,
including members of organized crime)
7. Combinations of the above working together in collusion.
Civil monetary penalties CMP's
Give this one a try later!
Penalties that may be imposed for a variety of conduct including Medicare
FWA. Different amts. of penalties and assessments may be authorized based
on the type of violation and can range as high as $50,000 per violation.
Example: Presenting a claim that a person knows or should know is for a
service that was NOT provided as claimed or is false and fraudulent.
, Legal Tools Against FWA (to Combat FWA)
Give this one a try later!
There are several legal tools that the government can employ in its fight
against FWA, including the following statutes:
1. Federal Civil False Claims Act
2. Anti-Kickback Statute
3. Physician Self-Referral Law (Stark Legislation)
4. Criminal Health care Fraud Statute
5. Criminal False Statements Act
6. HIPPA and HITECH Act
**Violations of these laws can result in non-payment of claims, imposition of
CIVIIL MONETARY PENALTIES, exclusions from the Medicare program,
imprisonment and criminal and civil liability.
FWA Related to Agents and Brokers
Give this one a try later!
--An agent offers Medicare beneficiaries cash or other impermissible
incentives to enroll in the Rx plan he represents.
--An agent offers beneficiaries money for names, address and phone
numbers of friends and acquaintances who are Medicare beneficiaries.
--An agent forges a beneficiary's signature on an enrollment form.
--An agent intentionally misrepresents a plan's costs or benefits for the
purpose of attaining enrollment, or convincing someone to enroll.
--An individual solicits MA enrollments and gather "initial premiums". She is
not really an agent and disappears with the money.
