FROM MY PT SCHOOL NOTES · HEALTHCARE SYSTEMS · UNIT 2 · CHAPTER 10
Fraud, abuse and referral integrity
10 Fraud, abuse and referral integrity What is the danger of a billing shortcut that “everyone uses”?
Core ideas from class
- The class shorthand “fraud is intentional; abuse is not” is not a complete legal test. Separate false claims, billing errors, medically unnecessary care, referral inducements and the applicable federal or state laws.
- Key legal topics include false claims, the Anti-Kickback Statute, physician self-referral/Stark restrictions, exclusions and civil monetary penalties.
- Examples worth screening: billing a no-show, inventing treatment minutes, upcoding, inappropriate referral gifts and unsupported medical necessity.
Think like a PT
A marketer proposes cash rewards for referrals of Medicare patients. Stop the plan and request a formal compliance assessment before any agreement.
Remember
Revenue pressure never makes unsupported care or false claims acceptable.
From my class sources: 14 Fraud and Abuse.pdf. These are personal school notes with additional editorial context, not current legal advice, payer guidance, a coding manual, or a guaranteed reimbursement rule. Verify any current policy directly.
