Glossary CM-COS
CME Fraud – See Continuing Medical Education (CME) Fraud in this Glossary;
CMH Fraud - Fraud typically occurs with unnecessary admissions/falsification of patient diagnosis, and misrepresentation of services provided. See Community Mental Health Center in this Glossary.
CMHC Fraud – See Community Mental Health Center (CMHC) Fraud in this Glossary.
CMN Fraud – See Certificate of Medical Necessity Fraud in this Glossary.
CMN Kickback Fraud – See Certificate of Medical Necessity Fraud in this Glossary.
Coding false claim – involves submitting claims for services or products with the use of billing codes resulting in a higher reimbursement than the code(s) that should have been used. See also Ambulatory Payment Classifications Fraud in this Glossary, and See Diagnosis Related Groups Fraud in this Glossary.
Community Mental Health Center (CMHC) - A CMHC may receive Medicare reimbursement for partial hospitalization services only if it demonstrates that it provides “core services” they include (a) Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically mentally ill, and residents of the CMHC’s mental health service area who have been discharged from inpatient treatment at a mental health facility; (b) 24 hour-a-day emergency care services; (c) Day treatment, or other partial hospitalization services, or psychosocial rehabilitation services; and (d) Screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission.
Compendium – a comprehensive listing of drugs and biologicals, which includes a summary of the pharmacologic characteristics of each drug or biological, and includes information on dosage, as well as recommended or endorsed uses in specific diseases. Specific compendium are referred to in coverage conditions for Medicaid and Medicare Outpatient prescription drug coverage.
Compound Medicine Fraud - the mass manufacturing of drugs that are the same or similar to drugs already available on the market, and without regard to the individual needs of the patient.
Comprehensive Outpatient Rehabilitation Facility (CORF) Fraud - a CORF is an outpatient facility established and operated exclusively for the purpose of providing diagnostic, therapeutic, and restorative services for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician. CORFs are different from other therapy providers in that, in addition to physical therapy, regulations require that they offer psychological or social services and the services of a physician who specializes in rehabilitation medicine. They are also unique in their authority to provide a variety of nontherapy services-such as respiratory treatment or nursing care-as medically necessary in the context of a patient’s rehabilitation therapy treatment plan. In general, services are provided on the CORF premises at a single, fixed location. Back disorders, arthritis, soft tissue injuries (such as joint sprains and strains), and neurologic disorders (such as concussion) are common conditions treated at CORFs. Common fraud patterns at CORFs revolve around overutilization of services, including billing for medically unnecessary therapy services (such as for therapy services related to maintaining rather than improving a patient’s functioning),and claims for the same beneficiary made by more than one CORF (often with common ownership so as to avoid scrutiny by spreading out the claims).
Continuing Medical Education Fraud - Education for health care professionals (post-graduation) styled as lectures, seminars, workshops, and consultant meetings. CME has been used by certain pharmaceutical companies to provide kickbacks to physicians under the guise of CME.
CORF Fraud - See Comprehensive Outpatient Rehabilitation Facility (CORF) Fraud.
Corporate Integrity Agreement (CIA) - often executed as part of a healthcare fraud False Claims Act settlement, it is an agreement between the Office of the Inspector General of the Department of Health and Human Services and a health care provider or other entity as part of a settlement for alleged civil wrongdoing. Each CIA is unique to the entity and its conduct, but a typical CIA will last for five years and will require the entity to implement procedures to comply with Federal health care laws, often including developing a compliance plan and hiring a compliance officer. Documents submitted to the Federal Government as part of compliance with a CIA have been the subject of qui tam False Claims Act lawsuits.
Cost Report Audit - because of the sizeable volume of Cost Reports submitted to fiscal intermediaries, only some Cost Reports receive a full audit, including a field visit by the intermediary to the hospital to compare the Cost Reports with the hospital’s internal financial statements and records. Most Cost Reports receive only cursory review. However extensive the audit is,it is not uncommon during the process of preparing and filing the Cost Report, Notice of Program Reimbursement (NPR) and if applicable, subsequent appeals, for the Provider and Fiscal Intermediary to exchange information in order to reconcile any differences in their calculations or conflicting interpretations of Medicare regulations. As a result of this reconciliation process, the Provider sometimes prepares and files amended Cost Reports, and the Fiscal Intermediary occasionally prepares and issues amended NPRs. The lack of audits increases the likelihood of fraud.
Cost Report Certification - Health care providers sign a certification on each cost report that they sign certifying that the provider has “complied with Medicare laws and regulations, and that the services identified in the cost report were provided in compliance with such laws and regulations.” Many qui tam False Claims Act cases have been successfully brought based upon a providers certification in its cost report that the services identity in the cost report were provided in compliance with the law.
Cost Report Fraud - Throughout the course of the fiscal year, certain providers submit claims to their assigned Fiscal Intermediaries for Medicare reimbursement. Generally, these claims are submitted based upon the number of discharged Medicare beneficiaries. To enable them to satisfy their operating need for cash, providers receive periodic interim payments based on estimated Medicare costs. Within a specified time after the end of the fiscal year, usually around April of each year, provider hospitals submit a Form (the “Cost “Report”) to their Fiscal Intermediary, setting out the costs they actually incurred. Including unallowable costs, and inflated costs are common violations of the False Claims Act.