Glossary CON – COS

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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.