* Managing Healthcare Fraud Investigations
Expert-defined terms from the Professional Certificate in Healthcare Fraud Investigation course at HealthCareStudies (An LSPM brand). Free to read, free to share, paired with a globally recognised certification pathway.
Accreditation #
The process of recognizing a healthcare organization or program as meeting certain standards of quality. Relates to healthcare fraud investigations as accreditation bodies may require healthcare organizations to have fraud prevention and detection measures in place.
Anti #
Kickback Statute (AKS): A federal law that prohibits the exchange of anything of value in return for referrals of federal healthcare program business. Violations of the AKS can result in criminal and civil penalties, including fines and imprisonment.
Claim #
A request for payment for healthcare services provided to a patient. Can be paper or electronic and is submitted to a healthcare payer, such as Medicare or Medicaid, for reimbursement.
Compliance Program #
A set of internal controls and procedures implemented by a healthcare organization to prevent and detect fraud, waste, and abuse. Can include policies, training, and audits.
Data Analysis #
The process of examining and interpreting data to identify patterns, trends, and outliers. In the context of healthcare fraud investigations, data analysis can be used to identify potential fraud, waste, and abuse.
False Claims Act (FCA) #
A federal law that prohibits the submission of false or fraudulent claims to the government. Violations of the FCA can result in criminal and civil penalties, including fines and imprisonment.
Fraud #
The intentional deception or misrepresentation made for the purpose of financial gain. In the context of healthcare, fraud can include billing for services not rendered, upcoding, and unbundling.
Healthcare Fraud Investigator #
A professional who is responsible for identifying, investigating, and preventing healthcare fraud. May work for a government agency, insurance company, or private firm.
Medicare #
A federal health insurance program for people age 65 and older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
Medicaid #
A joint federal-state health insurance program for low-income individuals and families.
Mental Health Parity and Addiction Equity Act (MHPAEA) #
A federal law that requires health insurance plans to provide the same level of coverage for mental health and substance use disorder benefits as they do for medical and surgical benefits.
Qui Tam #
A provision of the False Claims Act that allows private citizens to bring a lawsuit on behalf of the government and share in any recovery.
Stark Law #
A federal law that prohibits physicians from referring patients for certain designated health services to entities with which they have a financial relationship, unless an exception applies.
Upcoding #
The practice of billing for a more expensive service than was actually provided, in order to increase reimbursement.
Unbundling #
The practice of billing for multiple procedures or services separately, rather than as a single bundled rate, in order to increase reimbursement.
Whistleblower #
An individual who reports suspected illegal or unethical activities, such as healthcare fraud. Can be a current or former employee of a healthcare organization or a contractor.
Waste #
The overutilization of healthcare services, or the misuse of resources, that does not result in unnecessary costs to the healthcare system.
ZPIC (Zone Program Integrity Contractor) #
A contractor hired by the Centers for Medicare and Medicaid Services (CMS) to detect and prevent healthcare fraud, waste, and abuse in Medicare.