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False negatives

Occur when the patient’s medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully managed care capitated plans because the provider does not need to submit an encounter in order to receive payment for the service and therefore may have a weaker incentive to conform to data collection standards.

False positives

Occur when the encounter data contain evidence of a medical service that is not documented in the patient’s medical record. If we assume that the medical record contains complete information on the patient’s medical history, a false positive may be considered a fraudulent service. In a fully managed care capitated environment, however, the provider would receive no additional reimbursement for the submission of a false-positive encounter.

FALSE PRETENSE, TRICK, AND DEVICE

Garage liability for automobile dealers excludes losses resulting from fraudulent acts committed by customers or potential customers. For example, suppose a customer goes to a dealership and wants to test drive a car. The salesperson allows the customer to drive the car alone and the customer steals the auto and drives to another state. Under the exclusion in the garage policy, the dealer has no coverage for the value of the car.A false pretense, trick, and device endorsement removes this exclusion. It also covers such possible losses as a dealer taking a car in trade to which the customer did not have legal title. The coverage is designed for automobile dealers but is also purchased by other entities that occasionally engage in the selling of automobiles such as banks and credit unions. (See Garage Liability).

False swearing

If the insured lies under oath the policy is void whether the lie is in a proof of loss or at an examination under oath. The lie could be on the proof of loss statement, statements made to the carrier about the claim, statements made in the examination under oath, statements made on the application that the insured knows to be false. The difference between fraud and false swearing is that since false swearing involves a false statement made under oath, it is harder for the person to back off from the false statements when confronted.

Falsification of Accounts

Willful and with intent to defraud, destroying, altering, mutilating or falsifying any book (electronic record), paper, writing, valuable security or account belonging to Employer or deemed to be in his custody by one or more of clerk, officer or servant or employed or acting in any such capacity. The document is received by such person for or on behalf of his employer and he willfully and with intent to defraud made or abets the making of any false entry in or omits or alters or abets the omission or alternation of any material particular from or in any such book, electronic record, paper, writing, valuable security or account etc. It shall be sufficient in any charge to allege a general intent to defraud without naming any particular person intended to be defrauded or specifying any particular sum of money intended to be the subject of the fraud, or any particular day on which the offence was committed. (Section 477.A of Indian Penal Code).

Family and Medical Leave Act (FMLA) of 1993

A law allowing employees to take up to 12 weeks annually of job-protected unpaid leave. Such leaves are permitted in the event of a serious illness of the employee or family member, or the birth or placement (through adoption or foster care) of a child. The law applies to employers having 50 or more employees and to employees who have worked for the employer for a minimum of 1,250 hours during the prior year. Charges of discrimination against those taking leave under the Act (or by those prevented from taking leave under the Act) can be filed with the Department of Labor, which investigates and enforces claims. In addition, an employee can sue his or her employer individually. Such claims are covered by employment practices liability (EPL) policies.

Family and Medical Leave Act of 1993 (FMLA)

Federal law requires that covered employers must grant an eligible employee up to a total of 12 workweeks of unpaid leave during any 12-month period for one or more of the following reasons:• For the birth and care of the newborn child of the employee• For placement with the employee of a son or daughter for adoption or foster care• To care for an immediate family member (spouse, child, or parent) with a serious health condition• To take medical leave when the employee is unable to work because of a serious health condition