Biomaterial Database

Medicaid/Medicare fraud and abuse: practical guidelines for physicians. 1987

H G Gleitz, and A R Chenen

Administrative and judicial interpretation of the Medicare and Medicaid Fraud and Abuse laws--particularly provisions on illegal referrals--pose a threat to physicians considering new business arrangements. This article sets out examples of arrangements likely to avoid claims of Fraud and Abuse and shows how certain modifications may substantially increase the risk of government charges of illegal referrals.

UI	MeSH Term	Description	Entries
D008484	Medicaid	Federal program, created by Public Law 89-97, Title XIX, a 1965 amendment to the Social Security Act, administered by the states, that provides health care benefits to indigent and medically indigent persons.	Dental Medicaid Program,Medical Assistance, Title 19,Dental Medicaid Programs,Medicaid Program, Dental,Medicaid Programs, Dental,Program, Dental Medicaid,Programs, Dental Medicaid
D010816	Physician Incentive Plans	Compensatory plans designed to motivate physicians in relation to patient referral, physician recruitment, and efficient use of the health facility.	Incentive Plans, Physician,Incentive Plan, Physician,Physician Incentive Plan,Plan, Physician Incentive,Plans, Physician Incentive
D010820	Physicians	Individuals licensed to practice medicine.	Physician
D012017	Referral and Consultation	The practice of sending a patient to another program or practitioner for services or advice which the referring source is not prepared to provide.	Consultation,Gatekeepers, Health Service,Hospital Referral,Second Opinion,Consultation and Referral,Health Service Gatekeepers,Hospital Referrals,Referral,Referral, Hospital,Referrals, Hospital,Consultations,Gatekeeper, Health Service,Health Service Gatekeeper,Opinion, Second,Opinions, Second,Referrals,Second Opinions
D003415	Crime	A violation of the criminal law, i.e., a breach of the conduct code specifically sanctioned by the state, which through its administrative agencies prosecutes offenders and imposes and administers punishments. The concept includes unacceptable actions whether prosecuted or going unpunished.	Kidnapping,Poaching,Crimes,Kidnappings
D005607	Fraud	Exploitation through misrepresentation of the facts or concealment of the purposes of the exploiter.	Fraud, Health Care,Health Care Fraud,Kickbacks,Drug Counterfeiting,Healthcare Fraud,Counterfeiting, Drug,Fraud, Healthcare,Health Care Frauds,Kickback
D006278	Medicare	Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)	Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006759	Hospital-Physician Joint Ventures	A formal financial agreement made between one or more physicians and a hospital to provide ambulatory alternative services to those patients who do not require hospitalization.	Joint Ventures, Hospital-Physician,Physician-Hospital Organizations,Hospital-Physician Joint Venture,Hospital-Physician Organizations,Joint Venture, Hospital-Physician,Joint Ventures,Organizations, Hospital-Physician,Organizations, Physician-Hospital,Hospital Physician Joint Venture,Hospital Physician Joint Ventures,Hospital Physician Organizations,Hospital-Physician Organization,Joint Venture,Joint Venture, Hospital Physician,Joint Ventures, Hospital Physician,Organization, Hospital-Physician,Organization, Physician-Hospital,Organizations, Hospital Physician,Organizations, Physician Hospital,Physician Hospital Organizations,Physician-Hospital Organization,Venture, Hospital-Physician Joint,Venture, Joint,Ventures, Hospital-Physician Joint,Ventures, Joint
D006761	Hospitals	Institutions with an organized medical staff which provide medical care to patients.	Hospital
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.