QAPI Program Utilization_Manual

COMPLIANCE PROGRAM QUARTERLY REPORT, Year ________ 1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter IDENTITY THEFT / RED FLAG Case in the Period: _________ Reported to Authorities N/A Explain incident(s): _______________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Identity Theft Victims assisted: ________________________________________________________ N/A Occurs Patient Misidentification?: Yes No If yes, explain: __________________________________ _______________________________________________________________________________________ FRAUD PREVENTION Was completed the Billing/Financial report by the Administrator (Attach copy) Strategies to Prevent Fraud and Abuse in place Anonymous Reporting implemented Cost Report completed, audited False Statements and Kickbacks, Bribes, and Rebates prevented Description of Fraud distributed to all patients as part of Admission process Misrepresentation prevented Schedule of visit compliance, verified Services rendered in base of orders received and to cover patients needs only Internal control mechanisms are in place to preclude the following prohibited activities from occurring : Billing for items or services not rendered, Billing for medically unnecessary services, Duplicate billing Filing of false cost report, Failure to refund credit balances Provision of incentives to referral sources Joint ventures between parties to incite referral Physician self-referral law violations Billing for non-homebound patient services Billing for visits to patients who do not require a qualifying service Over/under-utilization, Billing for inadequate or substandard care Billing with insufficient documentation that services were performed Billing for home health coordination activities that are not allowable Billing for services provided by unlicensed or unqualified staff False dating of amendments to nursing clinical notes , misrepresentation Falsified Plan of Care, Untimely or forged physician plan of care certification Forged beneficiary signatures on visit notes of logs to verify services were performed Improper patient solicitation or marketing Inadequate oversight of subcontracted services, leading to improper billing Discriminatory admission and discharge of patients Billing for unallowable costs related to agency purchase or sale Compensation programs giving incentives based on visits and revenue generated improper influence over referrals by a hospital owing a home health agency Patient abandonment, Misuse of provider certification numbers, leading to improper billing Duplication of services provided by assisted living facilities, hospitals, clinics, physicians, or other home health agencies Providing service when an able and willing caregiver is available Failure to adhere to licensure requirements and Medicare Conditions of Participation (if applicable) Failure to return federal program overpayments 21