Med Law and Ethics - Mod 11 - Compliance in Healthcare

If a healthcare org determines that claims have been overpaid, it must report the overpayment and return the money within what time frame?

60 days after the overpayment was identified.

The OIG recommends that a comprehensive compliance plan include ____________.

7 elements

A brand new staff member in the billing department sends an account through to the insurance company for payment with too many codes on the claim. This results in a higher reimbursement for the facility. The new staff member is not yet aware of all of the rules and codes to check prior to sending the claim. How would this be classified?

Abuse

Which of the following protections are provided to a whistleblower? Select all that apply.

Cannot be demoted Cannot be fired Cannot be threatened Cannot be harassed

The False Act only targets which type of claims?

Claims the provider knew were false.

How much can a whistleblower be compensated?

Compensation may be up to 30% of any FCA recovery.

What is CERT?

Comprehensive Error Rate Testing - Program established by CMS to measure improper payments.

Southbank Hospital is the closest hospital to the military base. Soldiers receive most of their inpatient and outpatient services at this hospital. The soldier's care is covered by CHAMPUS. Periodically, the government performs an audit on the accounts of soldiers who have been treated at Southbank. Which governmental department will send employees to take care of the audits?

DCAA

Healthcare organizations strive to eliminate fraud and abuse. In addition to coding audits, what else can the healthcare organization do to help eliminate fraud and abuse?

Establish a compliance plan.

What are three benefits of implementing a compliance program?

Establishment of internal controls to ensure compliance. Demonstrates a commitment to appropriate corporate conduct. provides a method to obtain accurate assessment of behavior. Increased ability to id and prevent harmful behavior increased ability to respond to operational compliance concerns

T or F: CMS has one type of contractor that focuses on ensuring proper payments to Medicare and Medicaid programs?

False

T or F: The criminal penalty for an Anti-Kickback Statute Violation is up to $50,000 per violation

False

True or False? The Physician Self-Referral Statute is considered a criminal statute by the government.

False

True or False? The government defines a financial relationship as direct ownership by the referring physician or any members of the provider's immediate family.

False

The government implemented a litigation tool to combat fraud. Which of the following enable the government to fight fraud?

False Claims Act of 1986

What is FCA?

False Claims Act: passed in 1986 it is the primary litigation tool of the federal government. It states that anyone who "knowingly" submits fraudulent claims to the federal government can be held liable for civil penalties or prosecuted in criminal courts. Knowingly means that there was actual knowledge, deliberate ignorance, or reckless disregard when falsifying information.

A hospital has received overpayment for several claims. The hospital has been notified of the overpayments and has 60 days to return them. Under what act can the hospital be held liable if they do not return the funds?

False claims act

T or F: Audits are not a part of policies and procedures that assist the organization to act ethically and lawfully?

False.

T or F: In a case involving a possible violation of the physician-self-referral law, the Office of Inspector General can pursue criminal action?

Falsle.

General Hospital's billing department discovered that they have received overpayment for some of the claims submitted. The employee who found this overpayment decides that she does not need to report it. The supervisor is performing an audit one year later and discovers the error. What would the employee's choice be classified as?

Fraud

What occurs in a healthcare setting with the intent to misrepresent or conceal information?

Fraud

Define "fraud" as it pertains to healthcare

Fraud is the intentional misrepresentation or concealment of information to gain undeserved profits or other benefits.

The county hospital received notice that there will be an audit of their Medicare accounts for fiscal year 2015. The government agency performing the audits flagged these Medicare accounts for potential improper billing processes resulting in increased reimbursement. Which governmental agency will oversee the audit?

HHS-OIG-OAS

The federal government has implemented programs to contend with healthcare fraud using enforcement of laws through the strategic use of a variety of programs including, but not limited to:

Health Care Fraud and Abuse Control (HCFAC) Healthcare Fraud Prevention and Enforcement Action Team (HEAT) Comprehensive Error Rate Testing Program (CERT) CMS has 2 of their own: MACs and several Program Integrity Contractors

What is HCFAC?

Health Care fraud and abuse control - HIPAA established program to combat fraud toward public or private health plans.

What is HEAT?

Healthcare Fraud Prevention and Enforcement Action Team - A joint venture between HHS and DOJ.

Dr. Smith has been accused of charging a higher-level of evaluation and management codes for the examinations he is performing on his Medicaid patients. Dr. Smith's attorney informs him that there will be a/an __________ audit of his accounts.

Medicaid Fraud Control Units

Dr. Bowman makes an investment within his group medical practice. He receives compensation from insurance companies for the care he provides to his patients. Does Dr. Bowman's investment violate the Anti-Kickback Statute? Why or why not?

No; This is part of the safe harbor exception.

What is the Anti-Kickback statute?

Prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by federal healthcare programs. (drugs, supplies, healthcare services for medicare or medicaid patients) Remuneration includes things of value that may not be cash, including rent, food, expensive hotel stays, meals.

What types of false claims are included in the FCA?

Services not rendered, services already covered under another claim, miscoded services, and services not supported by medical record documentation.

A healthcare organization should ensure that their coding professionals receive annual education to maintain their skills. In addition to the education, what else should coding professionals review to ensure coding compliance?

Standards of Ethical Coding

Which of the following is another name for the Physician Self-Referral Statute?

Stark Law

What is Stark Law?

Stark law prohibits a physician from referring a patient to receive designated health services (DHS) that are payable by medicare or medicaid, to an entity that is a family member, or that they have a directly financial relationship with.

What are the three statutes that pertain to fraud and abuse?

The False Claims Act (FCA), the physician self-referral law (Stark Law), and the Anti-Kickback Statute.

Define "abuse" as it pertains to healthcare

The acts in question cannot be proven to have been intentionally committed.

What are the penalties if a provider does not comply with the False Claims Act?

The provider can be penalized up to three times the program's loss plus $11,000 per claim.

Bonnie is the coding supervisor at a local hospital and is performing audits when she discovers that one of her coding professionals has been incorrectly assigning a code for a procedure that results in a higher reimbursement rate. She speaks to the coding professional and provides education about which code is appropriate. True or False? The incorrect assignment of codes resulting in higher reimbursement rates is classified as upcoding and considered to be fraudulent behavior.

True

T or F: AHIMA Standards of Ethical Coding support selection of appropriate diagnostic, procedure, and other types of health service-related to codes.

True

T or F: According to CMS, false claims are known to the provider to be false?

True

T or F: An individual who notifies the government of a fraudulent act is called a whistleblower?

True

T or F: An unintentional error is not fraud?

True

T or F: Exceptions to the Anti-Kickback Statue are called safe harbor?

True

T or F: Failing to correct an unintentional error once it is discovered can be considered fraud?

True

T or F: In addition to the federal audits, there are state, local, and private health plan audits?

True

T or F: The office of Inspector General recommends that a comprehensive compliance plan as best practice for healthcare organizations?

True

Most surgical procedures include a global package. This means that even though there are many components to a procedure, all are combined into one billable package. Sarah codes for the local hospital and is working on coding a complex procedure. The patient has an open fracture that requires debridement and fixation of the fracture. Sarah decides to code the open fracture and the debridement procedure separately, instead of in the global package. What would this be labeled?

Unbundling

Billing for individual components of a complete procedure is considered to be _____

Unbundling.

What are considered a direct or indirect result of healthcare abuse?

Unnecessary costs to healthcare programs improper payment services that are medically unnecessary Services that fail to meet professionally standards of care.

A coding professional is reviewing a patient's chart for coding. The coding professional recognizes that the doctor performed a procedure involving only debridement to the level of the fascia. However, the patient had been in the facility for many weeks pre- and post- procedure, so the coding professional decides that coding the debridement to the level of the muscle would provide more reimbursement for this patient. How would this issue be identified?

Upcoding

The radiology department hired Julie to be their coding professional in charge of reviewing the radiology charts and assigning the appropriate procedure codes. Dr. Smith has been frustrated with his reimbursement rate for his radiology procedures. He sits down with Julie and talks to her about how he can improve his reimbursement. He tells Julie that even though the procedure takes him 15 minutes to perform, he will document 30 minutes so she can code it accordingly. They agree on this, and Julie assigns the code that corresponds with the longer length of time. How is this classified?

Upcoding

_______ is the assignment of the wrong billing code to an insurance claim in an effort to increase reimbursement for a service.

Upcoding

What are two coding examples of medical fraud?

Upcoding and unbundling

The OIG recommends a comprehensive compliance plan to include 7 elements. Name three

Use policies and procedures and written standards of conduct to promote a commitment of compliance. Designate a chief compliance officer Develop and implement regular training programs Develop a process to receive complaints. Establish and enforce a process for responding to allegations. Monitor compliance and identify problem areas using audits and other evaluation techniques. Generate policies to address non-employment or retention sanctioned individuals, as well as to investigate and remedy problems.

If a provider makes an unintentional billing mistake on a medicare claim, do they have to repay the federal government?

Yes

If an unintentional coding error resulted in overpayment by an insurance company, is this fraud?

Yes.

If the Stark Law is considered a civil statute, then the Anti-Kickback Statute is considered to be __________.

criminal

The manufacturer of a medication promised Dr. Andrews a monetary percentage for every prescription he writes. If Dr. Andrews prescribes this medication to his patients, he receives a __________.

kickback

What is upcoding?

selecting a higher level code than needed for services performed. Example: billing a service that was performed by a nurse as having been performed by a doctor.

What is unbundling?

using more codes than necessary to gain larger payments rather than selecting a single code that includes all the services performed in one. Example: when a lab test is done for a panel, all the different substances tested for should be covered under one panel code, not coded individually per test.

As the new HIM director for Community Hospital, Janice discovers that her coding manager has been authorizing the assignment of inappropriate codes to increase reimbursement for the hospital for over two years. Given the length of time this practice has been going on in the organization, it will mean a huge financial loss to report and repay Medicare. When Janice reports her findings to the CFO, the CFO instructs her not to file a report with Medicare and threatens termination if she does. Janice gathers information, including copies of accounts, that demonstrates a longstanding pattern of inappropriate upcoding. She calls the Medicare fraud hotline and reports her findings. Because of her actions, Janice is considered to be a/an __________.

whistleblower