CMS Fraud Definition
Making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from a federal healthcare program
CMS Abuse Definition
An action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
CMS Examples o...
✓ Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law
✓ Anti-Kickback applies to anyone, not just physicians; the Anti-Kickback
Law requires proof of intention and states that the person must
"knowingly and willfully" violate the law.
Exclusion Statute
✓ Under the Exclusion Statute, a physician who is convicted of a criminal
offense—such as Medicare fraud (both misdemeanor and felony
convictions), patient abuse and neglect, or illegal distribution of
controlled substances—can be banned from participating in Medicare
by the OIG. Physicians who are excluded may not directly or indirectly
bill the federal government for the services they provide to Medicare
patients.
List of Excluded Individuals/Entities (LEIE)
Master01 | September, 2024/2025 | Latest update
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