ABSTRACT
Contents Objectives ................................................................................................................................252 Introduction .............................................................................................................................252 Defi nition of Fraud ..................................................................................................................252 Overview of Legislation that Impacts Healthcare Fraud ............................................................253 Stark Laws ................................................................................................................................255 Overview of Healthcare Expenditures and Reimbursement
Methodologies .................................................................................................................256 Case Evaluation Methodology ................................................................................................. 262 Applications .............................................................................................................................267 2007 Enforcement Action: Patient Dumping ...........................................................................267 2007 Enforcement Action: False and Fraudulent Claims ......................................................... 268 2007 Enforcement Action: False and Fraudulent Claims ......................................................... 269 2007 Enforcement Action: Kickback and Physician Self Referral ............................................. 269 2007 Enforcement Action: Overcharging Benefi ciaries .............................................................270 Conclusions .............................................................................................................................271 References ................................................................................................................................271 Test Questions ......................................................................................................................... 272
Objectives Understand the mechanics of health care reimbursement ◾ Understand the elements of health care fraud ◾ Provide a case evaluation infrastructure for government sponsored health plans ◾
Introduction Fraud is defi ned as an intentional deception resulting in injury to another. Assessment of fraud within a government-sponsored health plan is complex by defi nition. Th is chapter will focus on distinguishing normal behavior patterns from those that are potentially fraudulent and which should trigger a more thorough review. Materials and data that are appropriate for such a review are discussed and applied to various scenarios. Appropriate guidelines for drawing conclusions from the information and materials reviewed are presented. After a review of this chapter, the legal nurse consultant will have a fundamental guide and standardized approach for the evaluation of cases involving potential fraud and/or abuse within a governmentsponsored benefi t plan.
