Glossary P – PH

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Part A Fraud – Fraud involving Part A of Medicare which pays for hospital inpatient, nursing facility, home health, and hospice care.

Partial Hospitalization Program (PHP) Fraud – Partial hospitalization is defined as a time-limited, ambulatory, active treatment program that offers therapeutically intensive, coordinated, and structured clinical services within a stable therapeutic milieu. Partial hospitalization programs serve patients who exhibit psychiatric symptoms, disturbances of conduct, and decompensating conditions affecting mental health. Fraud includes admission of patients who do not meet criteria, falsification of services rendered, and lack of providing group services yet billing for them.

Peer Review Fraud – See Peer Review Organization Fraud in this Glossary

Peer Review Organizations (PROs) Fraud – CMS enters into contracts with PRO’s to review services furnished by physicians, other health care practitioners, and institutional and non-institutional providers of health care services, including health maintenance organizations and capitated medical plans, as specified in their contract with CMS. The reviews are generally to determine whether those services are reasonable, medically necessary, furnished in the appropriate setting, and of a quality that meets professionally recognized standards of health care They are paid by submitting monthly cost reports called “vouchers.” The costs are based on a budget, and the budget is based on projected costs which may increase or decrease based on expenses, subject to a cap. Several PRO’s have been the subject of fraud investigations and qui tam lawsuits, all arising from fabrications in their cost reports.

Pharmaceutical Fraud – any fraud having to do with or stemming from the approval, manufacture, marketing, distribution or pricing of pharmaceutical products.

Pharmaceutical Fraud attorney – an attorney with experience handling pharmaceutical fraud cases.

Pharmaceutical kickback – a pharmaceutical company bribes or gives incentives to physicians or other healthcare professionals to prescribe and favor their drugs. It involves home-office-planned kickback schemes implemented by the field force under the guise of a legitimate reason to pay physicians or other providers. These include but are not limited to phony Phase IV trials, consultant agreements, advisory boards, preceptorships and so on. Examples of names given to kickback schemes include Consultant Programs, Consensus Programs, Clinical Forums, Clinical Experience Programs, Roundtables, Clinical Learning Days, etc.

Pharmaceutical Pricing Fraud – when a pharmaceutical company intentionally falsifies amounts, sales, free goods, classifications of its drugs, for instance, in order to increase reimbursement or decrease rebates owed. Pricing measurements which would affect government reimbursement include AMP, ASP, and Best Price.

Pharmacy Benefit Managers (“PBMs”) – entities engaged by certain organizations, including Medicare/Medicaid managed care organizations, that attempt to control a health plan’s prescription drug costs. PBMs typically establish formularies that may include only certain drugs negotiated at a favorable price (or rebate) with the manufacturer, require prior authorization, and require a larger patient copayment for other drugs.

PHP Fraud – See Partial Hospitalization Fraud in this Glossary

Physician kickback – See Kickback Violation in this Glossary