The Medicaid Program seeks to maintain the highest ethical standards in the provision of medical benefits and services to its beneficiaries and works in conjunction with federal and state authorities to enforce bans on fraudulent practices. These practices may be by beneficiaries and / or health service providers hired to provide health care to the beneficiaries of the Medicaid / Vital Plan Program.
Fraud in medical care is greater every year. The Puerto Rico Medicaid Program and other state and federal agencies work together to prevent fraud. Here are some helpful tips on how you can help prevent fraud and abuse in medical care.
WHAT IS FRAUD, UNFAIR USE AND ABUSE?
In general terms, fraud is defined as an intentional deception or forgery made by a person with knowledge of the deception, which could result in an unauthorized benefit to her or someone else. It includes any act that constitutes fraud under federal or state laws. (42 CFR 455.2; Welfare and Institutions Code, section 14043.1 (i)).
Also, it is defined as the act of executing or attempting to deliberately execute a plan or argument to defraud a health care benefit program or obtain (through false or fraudulent statements or promises) money or property that is owned or is owned or under the custody or control of any health care benefits program. (18 U.S.C. § 1347)
Misuse refers to the excessive use of services or other practices that result, directly or indirectly, in unnecessary costs to the health system, including the Medicare and Medicaid programs. It is generally not considered the result of criminal negligence actions, but of the misuse of resources.
Abuse is considered to be practices that are incompatible with valid fiscal, commercial or medical practices that result in unnecessary cost to Medicaid / Medicare programs or reimbursements for services that are not medically necessary or who do not meet the recognized standards of medical care. This includes the practices of Members that have an unnecessary cost to the Medicaid / Medicare programs. (24 CFR 455.2 and as further defined in the & Welfare and Institutions Code, section 14043.1 (a).)
LAWS THAT COVER US:
Federal False Claims Act, title 31, section 3279, of the United States Code
The Federal False Claims Act is a federal statute that encompasses fraud related to federal government-funded contracts or programs, such as the Medicare and Medicaid programs. This law establishes responsibility for a person who deliberately presents or causes the submission of a false or fraudulent payment claim to the United States government. The term "deliberately" means that a person, regarding the information:
The act does not require evidence of a specific attempt to commit fraud against the United States government. On the contrary, health care providers can be prosecuted for a wide range of behaviors that cause fraudulent claims to be submitted to the government, such as deliberately making false statements, falsifying records, billing supplies or services twice, sending invoices by services never performed or supplies never delivered, or otherwise causing the submission of a false claim.
State Law on Fraudulent Claims Law 154 of July 23, 2018 of Puerto Rico, Chapter II, Article 2.01 - Medicaid Fraud Control Unit (MFCU - Medicaid Fraud Control Unit)
Puerto Rico State Fraudulent Claims Law (Law 154 of July 23, 2018) Contracts and Services of the Government of Puerto Rico; created by the Medicaid Fraud Control Unit attached to the Department of Justice of Puerto Rico, for the purpose of operating a system of investigation and prosecution or preferred for prosecution, of violations of state laws relating to fraud in the administration of the Program of Medicaid in Puerto Rico; the offer of medical services and the activities of health care providers under the State Medicaid Program.
For this purpose, the Unit will conduct investigations and promote the corresponding civil and criminal actions for the recovery and / or restitution of losses and damages caused to the Medicaid Program, including, but not limited to, actions under the protection of False Claims Law or any similar legislation.