Glossary – E-F

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Emergency Room Diagnostic X-rays Fraud – Physician interpretation of x-rays for emergency department patients Medicare reimbursement is limited to one interpretation, except that Medicare pays for a second interpretation, identified through the use of modifier 77, only under unusual circumstances; for instance, when the physician performing the initial interpretation believes a specialist is necessary. Questions to consider include whether the documentation the medical record support the second claim?

End-Stage Renal Disease Test Fraud – “routine tests” are performed on an ESRD patient’s blood every time the patient undergoes dialysis. Reimbursement for these tests are rolled into the lump-sum “composite payment” that the Medicare beneficiary’s dialysis provider receives from Medicare for regular dialysis services. Hence, routine tests that are billed separately to Medicare are false claims.

ESRD Fraud – See End-Stage Renal Disease Test Fraud in this Glossary;

Fair market value – relevant to Stark and Anti-Kickback violations, it means is the compensation that has been included in bona fide service agreements with comparable terms at the time of the agreement, where the price or compensation has not been determined in any manner that takes into account the volume or value of anticipated or actual referrals. With respect to rentals and leases, “fair market value” means the value of rental property for general commercial purposes (not taking into account its intended use). In the case of a lease of space, this value may not be adjusted to reflect the additional value the prospective lessee or lessor would attribute to the proximity or convenience to the lessor when the lessor is a potential source of patient referrals to the lessee. See Stark Law in this Glossary; See Kickback violation in this Glossary;