Chapter 10

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Red Flags Rule

- requires businesses and organizations to implement a written identity theft prevention program -enforced by the False Claims Act

Emergency Medical Treatment and Labor Act (EMTALA)

known as the patient antidumping statute -ensures public access to emergency services regardless of the ability to pay

Anti-Kickback Statute

makes knowingly offering, paying, soliciting, or receiving any remuneration to reward referrals to services reimbursable by a federal program a criminal offense.

conditions of participation

CMS developed health and safety standards for improving quality of care and protecting the health and safety of patients that must be met in order for a healthcare organization to participate in Medicare and Medicaid programs. The Standards are called

returned overpayments

EXAMPLES OF HIGH-RISK BILLING PRACTICES WHICH CREATE COMPLIANCE RISKS FOR HEALTHCARE ORGANIZATIONS INCLUDE ALL BUT WHICH OF THE FOLLOWING?

compliance plan

Establishing a process to receive complaints and a procedure to protect the anonymity of complainants is one of the required elements in a

Potentially Compensable Events (PCE)

an event that may result in financial liability for healthcare organization

true

If the qui tam lawsuit is not successful and the defendant wins, the whistleblower could be required to pay the defendant's attorney fees if the government did not join the case

fraud

Knowingly and willingly executing pr attempting to execute a scheme to obtain by means of false or fraudulent pretense, representations, or promises money or property owned by any healthcare benefit program is

HIPAA

Legislation which increases attention on investigating, preventing and prosecuting fraud and abuse in Medicare

incident reporting

Notification to risk manager of an unplanned or unusual occurrence, such as patient falls, medication errors, and employee injuries

•Natural threats (floods) •Technical/man-made (mechanical, biological) •Intentional acts (computer security)

There are three major categories of threats

true

The Red Flags rule required financial institutions and creditors to establish identity theft protection programs. These would likely only apply to healthcare organizations that use credit reports or furnish information to consumer reporting agencies as a regular part of business.

civil monetary penalties law

The legislation provides punitive fines imposed by a civil court to organizations that profit from illegal or unethical activities.

false claims act

This act is used to combat medicare fraud by penalizing those that submit incorrect information to the program

fraud

an intentional deception or misrepresentation

stark law

This law prohibits a physician from referring certain health services to an entity in which the physician (or member of immediate family) has an ownership or investment or with which physician has a compensation arrangement, unless an exception applies

Office of Inspector General

This organization provides new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services.

yes, protection is provided whether the allegations are found to be true or untrue

Under the False Claims Act, is protection provided to the individual who discloses the corruption to the authorities, also known as whistle-blower

fraud

a pharmacist who submits medicaid claims for reimbursement of brand name drugs when less expensive generic drugs were actually dispensed has committed the crime of

Emergency Medical Treatment Active Labor Act

Which Act was passed to stop the practice of refusing to treat people because of inability to pay or insufficient insurance?

provide annual reports of non-compliance

Which of the following is not one of the seven elements of a compliance program per CMS and the OIG's recommendations -provide annual reports of non compliance -estalbish a formalized compliance committee -measure effectiveness through ongoing audits -designate compliance officer

abuse

any practice that creates unnecessary cost to federal healthcare programs -practices that are inconsistent with sound fiscal, business, or medical practices

risk management

___ programs should include both identification of potentially compensable events and routine monitoring

enterprise risk management

______ is an ongoing risk management process that flows through an entity versus being applicable to only certain units or people of the entity

recovery audit contractors

as the coding supervisior, your job description includes working with agents who have been charges with detecting and correcting overpayments made to your hospital in the Medicare- Fee-for Service program. You will need to develop a professional relationship with

provider's documentation

coding and billing documentation must be based on the

office of the inspector general

coding compliance programs focus on preventing accusations of fraud and abuse in healthcare. Which organization from the Department of Health and Human Services provides guidance for Healthcare organizations in developing compliance programs

OIG audits

evaluates its annual work plan and is dedicated to combating fraud, waste and abuse by providing oversite and resources to improve the efficiency of the HHS programs

safe harbors

exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution

laws

federally enforceable

qui tam

healthcare fraud and abuse laws provide a whistleblower provision also known as

risk management plan

identification of threats and vulnerabilities, security measures, and implementation priorities are part of a health care organization's

fraud

if an HIM department acts in deliberate ignorance or in disregard to official coding guideline, it may be comitting

kickbacks

if an HIM department receives gifts from vendors in exchange for purchasing a specific encoder software, this is

regulations

implementation details of the law and are also legally enforceable

risk control

includes avoidance, prevention, reduction, segregation, and non-insurance transfer

MACs (Medicare Administrative Contractors)

perform pre-payment reviews to ensure services provided Medicare beneficiaries are covered and medically necessary

patients who are in active labor

the EMTALA law ensures medical care is delivered to which of the following patient groups

identity theft

the Fair and Accurate Credit Transactions Act Works to reduce...

made compliance programs mandatory

the deficit reduction act of 2006...

stark law

the federal physician self-referral statute is also known as the

the government's investigative powers

the fraud enforcement and recovery act expands...

both criminal and civil penalties

the intent of the seven fundamental elements to a compliance program are designed to deter non-compliance. What is the potential penalty from the federal government for healthcare non-compliance

Failure to use a comprehensive code to inappropriately maximize reimbursement

unbundling refers to

if they submit a false claim to the federal government

under the false claims act, any person can be held liable if they knowingly submit a fraudulent claim to whom

exclusion and civil penalties

violations of EMTALA can result in

red flags rule

what is the name of the rule enacted by the false claims act which requires businesses and organizations to implement a written identity theft prevention program

intentional deception

which of the following accurately describes criminal healthcare fraud

MIA

which of the following groups are not federal programs used to control and monitor for healthcare fraud, waste, and abuse -RAC -HEAT -MAC -MIA

-conduct audit trails to monitor inappropriate access to system information

which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but not on the job description of chief privacy officer? -monitor the facility's business associate agreements -oversee the patient's right to inspect, amend, and restrict access to protected health information -conduct audit trails to monitor inappropriate access to system information -cooperate with the OCR in compliance investigations

a physician referring a patient to a dialysis center in which he is part owner

which of the following scenarios would violate stark law

RACs (Recovery Audit Contractors)

work with a mission of reducing Medicare improper payments through detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments

US Sentencing Commission Guidelines

•Defines individual and organizational criminal conduct •Defines sentencing and fines guidelines for individual and organizational criminal conduct •Provides compliance guidelines for reducing or preventing criminal conduct

corporate integrity agreements (CIA)

•are imposed when serious misconduct (fraud and abuse) is discovered through audits or self-disclosure and can last for several years. -•The OIG negotiates _____ with healthcare providers and entities so they are not excluded from participation in federal healthcare programs.

compliance officers

•are ultimately responsible for making sure employees adhere to a code of conduct and to provide timely reporting of compliance violations. -is responsible for identifying and locating primary law sources

HEAT (Health Care Fraud Prevention and Enforcement Action Team)

•identify fraud perpetrators and those preying on Medicare and Medicaid beneficiaries

corporate compliance program

•is designed to help detect and prevent the violations of fraud, waste, and abuse.

contingency planning

•is part of an emergency preparedness process and includes business practices, operational continuity, and disaster recovery planning. -includes plans to be followed in order to continue normal business operations

MICs (Medicaid Integrity Contractors)

•review Medicaid claims to determine potential provider waste or abuse, identify overpayments, and provide education to providers on payment integrity and quality of care issues

waste

•technically not a legal term; however, CMS identifies waste as encompassing over-utilization, under-utilization, and misuse of resources. •It is not typically intentional or criminal in nature but does have a financial impact on services.


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