Corporate Compliance refers to an organization's policies and procedures that comply with Federal, State, and third-party payor's rules and regulations. Increasing funding is being funneled to investigate, prosecute, audit, inspect, and educate to reduce fraud and abuse in these programs. Mail fraud and the False Claims Act are also considered in this concern. Health care fraud is willingly and knowingly making false statements in order to obtain payment or benefit that would not correctly be paid.
Fraud requires demonstration of intent.
Abuse encompasses practices which either directly or indirectly result in unnecessary costs to Medicare or Medicaid without the need to demonstrate intent. Abuse occurs when the practitioner knows or should have known the correct practices. Coding errors can include billing for equipment or services not provided, or billing for physician services when a mid-level practitioner, technician, or office personnel provide the service. Consultations pay more than an initial visit for a referral, but must show only an opinion or advice requested by the referring physician conveyed in writing. If further management is assumed by the consultant, subsequent visits must be billed as an established patient.