SA Reporting of Possible Certification Fraud

4004 - SA Reporting of Possible Certification Fraud (Rev. 96, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) Section 1128.B of the Act and P.L. 104.191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains specific penalties for fraud and abuse under Medicare and Medicaid. It provides criminal penalties for: • Making false statements or representation for any benefit or payment under Medicare and Medicaid; • Soliciting or receiving any kickback, bribe, or rebate; • Making false statements or representations with respect to the conditions or operation of any institution, facility, or entity in order to qualify (either initial certification or recertification) for participation in Medicare or Medicaid; • Charging for any services provided to a patient under Medicaid at a rate in excess of the established State rate, or charging, soliciting, accepting, or receiving in addition to any amounts otherwise required to be paid under Medicaid, any gift, money, donation, or other consideration as a precondition of admitting a patient to a hospital, NF, or ICF/IID, or a requirement for the patient’s continued stay in such a facility; • Charging for services not rendered; and • Physicians and suppliers who agree to accept assignment and violate the terms of that agreement. When the SA believes that there may be certification fraud, it should immediately notify the RO via memorandum. This memorandum should include the name and provider number of the facility, together with a statement of the relevant facts. In addition, the SA should make no further contacts with the offending individual or facility with respect to this matter unless requested to do so by the appropriate RO personnel. This is necessary because any unauthorized contacts may compromise the potential or pending investigation, including chances for successful prosecution of any criminal violation that has occurred.