CPCO CH. 4

Hospitals are prohibited from making payments, directly or indirectly, to a physician as an inducement to reduce or limit services provided to Medicare or Medicaid patients. The hospital is subject to a civil money penalty of not more than how much for each individual for whom a payment is made?

$2,000

The BBA of 1997 created an alternate sanction allowing the government to levy a civil fine of up to how much for each violation of the Anti-Kickback Statute?

$50,000, and an assessment of three times the amount of the kickback The government may levy a civil fine of up to $50,000 for each violation of the Anti-Kickback Statute, and an assessment of three times the amount of the kickback.

The FCA provides several circumstances when a relator cannot file or pursue a qui tam action:

1 - The relator was convicted of criminal conduct arising from his or her role in the FCA violation 2 - Another qui tam concerning the same conduct already has been filed (this is known as the "first to file bar") 3 - The government already is a party to a civil or administrative money proceeding concerning the same conduct 4 - The qui tam action is based upon information that has been disclosed to the public through any of several means: criminal, civil, or administrative hearings in which the government is a party, government hearings, audits, reports, or investigations, or through the news media (this is known as the "public disclosure bar"). There is an exception to the public disclosure bar where the relator was the original source of the information.

In a qui tam action in which the government intervenes, the relator is entitled to receive a monetary settlement between?

15- 25%

The ACA requires providers to refund an overpayment to Medicare within how many days of identifying it?

60

The Compliance Officer of Apple Internal Medicine Group explains to the Board that Stark law is similar to the ___________ but applies only to physician relationships with entities that bill Medicare or Medicaid.

Anti-Kickback Statute The Stark law is similar to the anti-kickback statute but applies only to physician relationships with entities that bill Medicare or Medicaid. When enacted in 1989, the Stark law only applied to physician referrals for clinical laboratory services.

The Compliance Officer at Apple Internal Medicine Group explains to the Board that there is a difference between the False Claims Act (FCA) Civil and Criminal law. What is the difference between them?

Criminal states that proof must be beyond a reasonable doubt. The FCA does not encompass mistakes, errors, or negligence. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.

The Medicare Modernization Act (MMA) of 2003 was implemented for which of the following to reduce medication errors due to physician's handwriting?

E-prescribing

A basic concept in the Anti-Kickback safe harbors and Stark exceptions is that financial transactions between potential referring parties be conducted under what condition?

Fair market value The Anti-Kickback statute also contains safe harbors (42 CFR 1001.952 (a)-(u)). Arrangements not fitting into a safe harbor do not automatically violate the anti-kickback law. A basic concept in the Anti-Kickback safe harbors and Stark exceptions is that financial transactions between potential referring parties be conducted at fair market value.

The OIG is a division of which agency?

HHS

The Office of Inspector General works from within what organization to identify vulnerabilities in the health care system?

Health and Human Services (HHS)

The OIG's publication of 5 Special Fraud Alerts addresses joint venture relationships.

Joint venture arrangements; Routine waiver of Medicare Part B copayments and deductibles; Hospital incentives to referring physicians; Prescription drug marketing practices; Arrangements for the provision of clinical laboratory services.

False Claims Act covers claims that are billed to

Medicare A,B,C, & D

The U.S. Department of Health & Human Services (HHS) oversees

Medicare, Medicaid, public health, medical research, food and drug safety, welfare, child and family services, disease prevention, Indian health, and mental health services; and, it exercises leadership in public health emergency preparedness and combating bioterrorism.

After hiring, how often should providers check to make sure employees are not on the OIG List of Excluded Individuals?

Monthly

The RICO Act is a law that increases the severity of penalties for violations of what?

Organized crime

Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for employing excluded entities or providers. How often should he check the OIG List of Excluded Individuals Entities on the OIG website?

Prior to hiring and monthly thereafter

Providers can give physicians gifts and other benefits up to a set amount each year, adjusted for inflation. Gifts and benefits should be tracked: If the set amount is exceeded, what can the physician do?

Repay the excess.

Under the False Claims Act a person or entity may voluntarily disclose a violation and if they cooperate with any ensuing investigation and satisfy certain other criteria, the damages will be doubled instead of tripled under what circumstance?

When there is no current criminal or civil enforcement action pending

The CMP Inflation Adjustment increased the maximum penalty amount per false claim to?

$10,957- $21,916, plus three times the amount claimed for damages. In 2017, the Civil Monetary Penalties Inflation Adjustment increased the penalty to $10,957- $21,916(effective for false claims made after November 2, 2016). Penalties for violation of this law are calculated through the CMP law (explained above) and range between $10,957- $21,916 for each false claim submitted, plus three times the amount of damages (the amount of the claim).

Exclusion can result from violating any section of the Civil Monetary Penalties Law, or from an individual or entity submitting a claim for reimbursement to a federal health care program for items or services furnished by an excluded person or entity. Penalties can be up to how much (prior to inflation)?

$11,000 per claim, plus treble damages for the amount claimed for each item or service.

Deficit Reduction Act provides

a financial incentive for states to enact false claims acts that establish liability to the state for the submission of false or fraudulent claims to the state's Medicaid program. If a state False Claims Act is determined to meet certain requirements, the state is entitled to receive a greater monetary recovery with respect to any amounts recovered under a state action brought under such a law.

The Stark law bans certain financial arrangements between

a referring physician and an entity that bills the Medicare or Medicaid programs. Specifically, if a physician (or immediate family member) has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services (DHS) for which the Medicare or Medicaid programs would otherwise pay.

Federal wire fraud (18 USC 1343) covers

any criminal fraudulent activity that is determined to involve electronic communications of any kind. The citation specifically states: "Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, transmits or causes to be transmitted by means of wire, radio, or television communication in interstate or foreign commerce, any writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or artifice, shall be fined under this title or imprisoned not more than 20 years, or both." This type of fraud involves such activities as transmitting claims for reimbursement through the Internet or Facsimile. It can also include telephone solicitation when fraud is the objective such as in the case of Medicare Parts C and D programs, supplemental insurance plans, private insurance programs, and DME solicitation. Fraudulent claims submitted electronically across state lines or internationally have the potential to be in violation of this statute.

The Balanced Budget Act (BBA)

authorized the imposition of Civil Monetary Penalties against health care providers and entities that employ or enter into contracts with excluded individuals or entities to provide items or services to federal program beneficiaries.

The Civil Monetary Penalty Law and the False Claims Act (FCA)—are related to proper claims filing. Mere mistakes, which can be remedied by returning overpayments...

do not result in violations of these laws.

Fraud and Abuse Recovery Act (FERA)

expands the grounds for liability under the False Claims Act.

The Racketeer Influenced and Corrupt Organizations (RICO) Act is a law that

increases the severity of penalties for violations involving organized crime

Anti-Kickback Statute

it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal healthcare program. The statute prohibits both the offer or payment of remuneration for patient referrals, and the offer or payment of anything of value in return for purchasing, leasing, ordering, arranging for, or recommending the purchase, lease, or ordering of any item or service that is reimbursable by a federal healthcare program.

So-called "circumnavigation schemes" may result in

monetary penalties of up to $100,000 for each arrangement or scheme, and exclusion from government programs. These occur when a physician or other entity enters an arrangement or scheme (such as a cross-referral arrangement) that the entity or person knew, or should have known, had the principal purpose of assuring referrals (which, if they had been made directly, would have been prohibited).

Two laws—the Anti-Kickback Statute and the Stark Law—relate...

primarily to the relationships between referral sources, such as physicians and hospitals.

Stark Law

prohibits payments for certain "Designated Health Services" provided through a prohibited referral and requires refunds for any amounts improperly billed and collected. It provides for a civil monetary penalty (up to $15,000 per service) and exclusion from government programs in any case where a person submits an improper claim, which was known to have been, or should have been known to have been, provided through a prohibited referral, and has not refunded the payment.

ivil actions may be brought in federal district court under the False Claims Act by

the attorney general, or by a relator (whistleblower), in a qui tam action.

Examples of anti-kickback statute violations include:

• A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital • Routine waiver of copayments or deductibles for patients under Medicare Part B • A drug or equipment supplier providing free benefits for a provider who utilizes their product • A physician who is paid exorbitantly for speaking engagements by a company to whom the provider refers business

When you find out that someone is excluded from federal programs, consider the following steps:

• At least temporarily remove them from providing services. Discuss whether that will include all services or just government program services with your legal counsel. • Any paperwork regarding the exclusion should be reviewed and the individual should only be returned to duty when there is documentation of government reinstatement. • An analysis should be done to first determine whether the person or entity was properly excluded, and the correct timeframe. Then the items or services they ordered or prescribed would be examined. • If items or services are not ordered or prescribed, the excluded person's salary, benefits, or contract cost would be analyzed to determine if they affect payment under a Medicare or Medicaid cost report.

What are designated health services?

• Clinical laboratory services • Physical therapy services • Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services • Radiation therapy services including supplies • Parenteral and enteral nutrients, equipment, and supplies • Prosthetics, orthotics, and prosthetic devices and supplies • Home health services • Outpatient prescription drugs • Inpatient and outpatient hospital services