Medicare, as well as other federal healthcare programs, depends on providers’ professional and clinical judgment to give patients quality care and provide medically necessary services. This course provides a basic understanding of Medicare fraud and abuse, emphasizing prevention. This information is designed as preparation material for presentations or to conduct training about these topics.
Section 1: Introduction
About This Course
Section 2: Overview of Fraud and Abuse
What Is Medicare?
What Is Medicare Fraud?
What Is Medicare Abuse?
What Is Medicare Waste?
Section 3: Societal Impact
Fraud and Abuse Perpetrators
Medicare Fraud and Abuse Laws
False Claims Act (FCA)
Anti-Kickback Statute (AKS)
Physician Self-Referral Law (Stark Law)
Social Security Act
The United States Criminal Code for Health Care Fraud
Clinical Impact of Fraud and Abuse
Medicare Marketing Rules
Section 4: Anti-Fraud and Abuse Partnerships
Medicare Anti-Fraud and Abuse Partnerships
Office of the Inspector General (OIG)
Health Care Fraud Prevention and Enforcement Action Team (HEAT)
Medicare Fraud Strike Force
General Services Administration (GSA)
Section 5: Fight Against Medicare Fraud
Fraud Prevention Tips
Section 6: Clinical Vignette
Section 7: Conclusion
Judy Campbell, MSN, RN, CCM has been a registered nurse since 2008. She is a subject matter expert in care coordination, which occurs at the intersection of patients, providers, and healthcare settings. As a certified case manager, her aim is to assist in transforming fragmented health systems to become coherent and manageable. To continue to cultivate her growth and entrepreneurial spirit, Judy is also a freelance writer that provides high-quality content for healthcare professionals. Disclosure: Judy Campbell, MSN, RN, CCM has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.Writer: Kimberly Workman, MA
Ms. Workman is an Instructional Designer at Relias. She has a Master of Arts in Technology and Communication, as well as graduate certificates in Public Health, Epidemiology, and Digital Communications. Ms. Workman has a background in writing and designing online continuing medical education for physicians and other health professionals on multiple educational platforms, including web-based, game-based, and immersive learning environments. She has also used simulation training extensively to connect learning to real-world environments. Disclosure: Kimberly Workman, MA discloses the following potential conflict of interests/commercial interests: Relevant Financial Relationship with Relias LLC as a Salaried Employee All of the relationships listed for this individual have been mitigated.Relevant Non-Financial Relationship with No Entities Exists as a Contributor All of the relationships listed for this individual have been mitigated.
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