Policies

Fraud Waste & Abuse

Violations of the Fraud & Abuse laws can result in significant fines, as well as penalties such exclusion from participation in healthcare programs.   In some cases, violations result in criminal charges.

False Claims 

Claims for payment of healthcare services may be considered false if the service is not actually rendered to the patient, is provided but already covered under another claim, is miscoded, or is not supported by the medical record.

The are several regulations addressing false claims that apply to USF.

  • The federal False Claims Act makes it illegal to submit false or fraudulent claims for payment to Medicare or Medicaid.   This statute is not intent based.  Fines for violations are significant and can add up quickly.  
  • Florida False Claims Act
  • USF Regulation 5.001, Fraud Prevention and Detection

USF Health is committed to integrity in its billing practices and has created a policy for Fraud, Waste, and Abuse prevention that includes mandatory provider education and reporting of known inaccurate billing under the protections of USF policy for prohibited relatiation.

Anti-Kickbacks & Stark 

Two federal statutes were created to prevent improper referral relationships.  Referrals should be based on an individual patient’s healthcare needs.

  1. Anti-Kickback Statutes (AKS)

In some industries, it is acceptable to offer, pay, solicit or receive anything of value to reward referrals of business; in healthcare it is a crime.

There are federal & state statutes that prohibit kickbacks in healthcare.

      • The federal anti-kickback statute is an intent-based, criminal statute that, as a general matter, prohibits payments in exchange for referrals or other Federal health care program business. There are defined safe harbors to prevent violations of this statute. This statute applies to both payers and recipients of kickbacks.
      • In Florida, it is unlawful for any health care provider to offer, pay, solicit, or receive a kickback, directly or indirectly in cash or in kind for referring or soliciting patients, reference: F.S. 465.054.

  2. Stark (Physician self-referral law)

Stark is a federal law that prevents physicians from referring a patient for a health care service (examples include lab tests, therapy, diagnostic tests/imaging, prescription drugs, durable medical equipment, and home health) to an entity in which the physician has a financial interest.  However, there are approved exceptions.

Stark law is meant to ensure physicians make referrals solely based on what is best for their patients, and not their own financial gain. 

Click here to view a detailed comparison of these two regulations.

USF Health is committed to quality patient care and has developed a policy for Prohibiting Required or Incentivized Referrals.