Policy Manual sample

MDT Home Health Care Agency, Inc. · Days of admission or treatment that have been improperly reported and would result in an overpayment if not adjusted. · Program data where provider or supplier program amounts cannot be supported. · Allocation of costs to related organizations that have been determined to be improper. What Constitutes Abuse Abuse describes practices that either directly indirectly result in unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and /or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. Differences between Fraud and Abuse Abuse describes practices that either directly or indirectly resulted in unnecessary costs to the Medicare Program. Fraud is distinguished from abuse in that, in the case of fraudulent acts, there is clear evidence that the acts were committed knowingly, willfully, and intentionally. Abusive billing practices, on the other hand, may not result from “intent”, or it may be impossible to determine that this intent to defraud existed. Although these types of practices may initially be categorized as abusive in nature, under certain circumstances they may develop into fraud if there is evidence that the subject was knowingly and willfully conducting an abusive practice. Examples of Abuse The following are examples of abuse from Chapter 6 of the Medicare Physician Guide: A resource for Residents, Practicing Physicians, and Other Health Care Professionals (previously titled Medicare Resident & New Physician Guide: Helping Health Care Professionals Navigate Medicare), which is available at www.cms.hhs.gov/MLNProducts/downloads/chapter6.pdf on the CMS website: · Charging in excess for services or supplies. · Providing medically unnecessary services. · Providing services that do not meet professionally recognized standards. · Billing Medicare based on a higher Fee Schedule than is used for patients not on Medicare. · Submitting bills to Medicare that are responsibility of other insurers under the MSP provisions. · Violating the participating physician, provider, or supplier agreement with Medicare or Medicaid. · Breaches in the assignment agreement. · Violating the Maximum Allowable Actual Charge Limits or the limitation amount when applicable. Significant Medicare Fraud and Abuse Provisions Anti-Kickback Statue Home Health Agency Policies A-142