PPS false claim -A false claim submitted by a provider that defrauds medicare’s Prospective Payment System.
PRO Fraud – See Peer Review Organization Fraud in this Glossary.
Referring physician – applicable to Stark Law violations, it is a physician who makes a referral or who directs another person or entity to make a referral or who controls referrals made by another person or entity. A referring physician and the professional corporation of which he or she is a sole owner are the same for purposes of the applicable healthcare fraud laws. See Stark Law in this Glossary.
Registry – A place where data, records and information are maintained and made available for research. They are often used by pharmaceutical companies, medical device manufacturers, and clinical laboratories. Physicians and other health care providers receive payment in exchange for the time and effort of enrolling patients in the registry, and providing the required data for each patient, to the Registry. When used improperly, Registry arrangements can violate the Anti-Kickback Statute. Also see Laboratory Fraud.
Related Party Fraud – See Related Party Rule below.
Related Party Rule – in the context of cost reports, the Rule requires that costs applicable to services, facilities, and supplies furnished to the provider, by organizations related to the provider by common ownership or control are includable in the allowable cost of the provider but only at the cost to the related organization. Failure to disclose Related Party status in Cost Reports has been the subject of several qui tam lawsuits. See Cost Report Fraud in this Glossary.
Remuneration – relevant to Stark Law and Anti-kickback violations, it is defined as “any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind (with limited exceptions”). The remuneration is typically made to induce a physician to certify or recertify of the need for, any designated health service ordered by or to be performed by (or under the supervision of) a second physician or healthcare provider including a hospital. Renumeration is often disguised so as to avoid Stark Law or Anti-kickback Law violations.
See Stark Law in this Glossary.
Research Fraud – See Clinical Trial Fraud in this Glossary.
Rural Referral Centers (RRC) – Rural hospitals which meet the criteria of an RPC have their prospective rate determined on the basis of the urban, rather then the rural adjusted standardized amounts, as adjusted by the applicable DRG weighting factor and the hospital’s area wage index. Favorable exceptions and adjustments to the standardized prospective payment amounts are taken into account with RRCs, including payment based upon the urban, rather than rural, prospective payment rates as adjusted by the applicable DRG weighting factor and the rural area index. To retain /RRC status a hospital must meet or exceed a certain level of case-mix index-it is this calculation that is subject to fraud and abuse.