Frequently Asked Questions About Compliance . Presented by: Penny Osmon Coding & Reimbursement Educator Wisconsin Medical Society [email protected] History of Compliance. Coding and compliance continue to be “hot topics” within the health care industry.
FIND IT – FIX IT – PREVENT IT
“Any health care entity which does not have a compliance program is institutionally nuts’”Karen MorrisetteDeputy Chief of the Criminal DivisionDivision Fraud Section of the U.S. Department of Justice
For most services, providers are required to indicate their usual and customary charge when submitting claims. The usual and customary charge is the provider’s charge for providing the same service to persons not entitled to the program’s benefits. For providers using a sliding fee scale, the usual and customary charge is the median of the individual provider’s charge for the service when provided to non-program patients. For providers who have not established usual and customary charges, the charge should be reasonably related to the provider’s cost for providing the service.
Source: Forward Health On-line Handbook, 2009
Fraud – making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.
Abuse – practices that, either directly or indirectly, result in unnecessary costs to the Medicare program or other payer.
Prohibits knowingly filing a false or fraudulent claim for payment to the government, knowingly using a false record or statement to obtain payment on a false claim or conspiring to defraud the government by getting a false claim paid.