Healthcare Compliance
The CMP inflation adjustment increase the maximum penalty amount for false claims to
$10,781-$21,563 plus the assessment of not more than three times the amount of claims for damages.
The balance budget act of 1997 created an alternate sanction allowing the government to levy a civil fine up to how much for each violation of anti-kickback statute?
$50,000 and an assessment of three times the amount of the kickback
What is the importance of compliance training?
1) all employees will receive training on how to perform their jobs in compliance with standards and practices in any applicable regulations, 2) each employee will understand the compliance is a condition of continued employment 3) compliance training focuses on explaining why the practice is developing a compliance program
What are the levels of in our MAC claims appeal process
1) redetermination by MAC, 2) reconsideration by a qualified improvement contractor, 3) hearing by an Administrstive Law Judge 4) review by the Medicare appeals council within the departmental appeals Board 5) judicial review in the US District Court
If an organization discovers credible evidence of the providers continued misconduct or fraudulent or abusive conduct, we will then enact the following procedure
1) suspend all submissions of any false or inappropriate claims. 2) terminate the contract. 3) if after review by our legal counsel, it is in our best interest to report the misconduct to appropriate federal or state authorities, we will do so within 60 days after determining that there is credible evidence of a violation
How many states require nursing facilities to perform FBI checks on employees?
10
In a QUI TAM action in which the government intervenes the relater is entitled to receive monetary settlement between
15 to 30%
What year did OSHA publish the blood-borne pathogen standard?
1991
In what year did the OIG post guidance for hospitals?
1998
Penalties for mail fraud for persons who knowingly and willingly schemes to defraud healthcare benefit programming could find in a prison term of up to how many years?
20 years
The typical duration of a corporate integrity Agreement?
3 to 5 years
Medicare requires physicians and mid-level providers to certify the need for physical, occupational, and speech therapy. The first certification is needed within how many days of starting therapy
30
Which code of federal regulations section is important to compliance officers, Why?
42, it covers Medicare and Medicaid programs
How many states currently require nursing facilities to perform a background check of state records for direct access employees?
43
The ACA and acted a CMP that requires a return of over payments within how many days of identifying them?
60
What are the time limitations for notification after a breach of PHI?
60 day notice requirement
The ACA requires providers to refund an over payment to Medicare within how many days of identification?
60 days
All providers must refund monies that are overpayments. By law, this must occur within
60 days of identification of overpayment
What are the estimates from the CDC regarding healthcare workers that sustain per cutaneous injuries annually?
600,000
Because it is such a large component of their responsibility, what percentage of resources does the OIG dictate to Medicare and Medicaid?
80 percent
Examples of false claims
A claim for service or supply that was never provided, a claim indicating that the service was provided for some diagnosis code other than the true diagnosis code in order to obtain reimbursement for the services, a claim indicating a higher level of service and was actually provided, the claim for service that the provider knows is not reasonable and necessary, it claims services provided by an unlicensed individual.
What do rat stats represent
A free statistical software that can be used to select random samples for audit.
What does OSHA look for in an exposure control plan
A list of employees in the process for an obtaining input, other documentation such as meeting minutes or records of employee responses, the organization safety policy currently in place that includes a requirement for annual training of employees.
What are the standard components of a CIA
A preamble, the term and scope, corporate integrity obligations, independent monitor, but disclosure program, in eligible persons, reporting, successor liability, implementation and annual reports, OIG inspection audit and review of rights, document and record retention, disclosures, breach in default provisions, effective and binding agreements, signatory page and appendices
Define reasonable and necessary
A service or supply that is provided within acceptable standards of medical practice for the diagnosis and treatment of a condition
Define conflict of interest
A set of circumstances that risk professional judgment or actions regarding a primary interest and will be unduly influenced by a secondary interest.
Fraud, waste, and abuse are all areas that must be controlled when providing services to beneficiaries. Fraudulent billing is
A willful act
What are the breach notification requirements
A written notification may be sent by mail or email, if mail or email addresses are known for 10 or more individuals, substitute notice maybe provided. Consider issues conspicuously posting on homepage a website or by using major print or broadcast media. When possible image misuse of unsecured PHI create urgency, notice maybe provided to individuals by telephone or other appropriate means. Noticed in the media is except a when the breach is likely to have included more than 500 individuals. Breaches involving more than 500 individuals must be reported immediately to the HHS secretary and will be posted on the agencies website. Breaches of less than 500 individuals will be logged by a covered entity and see me
What is considered an appropriate start to implement an effective the compliance program for compliance officers of small physician group practices with limited resources?
Adopt only those components which, based on the practice of specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit.
Unacceptable documentation for teaching physician?
Agree with the above, rounded, reviewed and agreed, discussed with resident and agree, seen and agree, patient seen in evaluated, a legible countersignature
What information must be disclosed related to alcohol and substance abuse
Alcohol and substance of views are regulated and they are not to be disclosed without permission from the patient in any circumstances the federal government restrict any use of the information to criminal investigator prosecute any alcohol or drug abuse patient
What are the time periods required for reporting injuries and illnesses to OSHA
All deaths need to be reported within eight hours and as a requirement to report related inpatient hospitalization amputations loss of an eye within 24 hours
When connecting to find training within a physician practice, what is one of the goals that practice should strive for in this training?
All employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations.
What should be readily of accessible to all coding staff?
All essential coding resources
The 250 yard zone rule does not apply to
All hospital own physician practices
When there is a notice of an investigation, employees must know that it is against policy to
Altar, destroy, or remove any documentation from a patient's medical record
Under patient protection or ACA of 2010 the following patient rights are legislated under Law
And a pre-existing conditions and exclusions for children and adults, he was young adults covered until 26, your case you're right to appeal
Government reporting for retirement plans
Annual report is a summary of financial, participant, the actual, and fiduciaries information. Annual reports must be filed on the 5500 series with the Dol within seven months after the close of the plan year.
Routine waiver of Medicare deductible or co-pay meant as a violation of which statue?
Anti-kickback
If a group hospital monthly rent for office space that is 1/2 the on going rate for fair market value, this is a violation of which regulation
Anti-kickback statute
What are the primary obligations under EMTALA?
Any individual who comes in emergency department must be provided an appropriate medical screening examination within the 250 yards of the hospital emergency department including ancillary services routinely available to medical screenings examinations
If a patient walks in your practice with a leash dog, what should you do?
Asked the patient if the dog is a service animal and, if efficiency just allowed at the Animal to be on the premises
Attorney client privilege protects communications that have with your attorney and?
Attorney-client work product
Why is the work plan so important to compliance officers when they are developing their risk assessments?
Because it shows the results of the previous year's audit findings and the current years focus
When did form 300A need to be posted to OSHA
Between February 1 and April 30th in a common area where employee notices are usually posted
What third-party plays a critical role in accurate billing and reimbursement?
Billing agencies
Risk areas under the OIG are
Billing and coding, fraudulent incident to billing, double billing resulting in duplicate payments, billing for noncovered services as if covered, knowing misuse of a provider identification, resulting in improper billing, unbundling, failure to properly use Coding modifiers, clustering, reasonable and necessary services, documentation
Risk areas of third-party billing companies
Billing for items or services not documented, unbundling, coding, diagnosis related group creep, inappropriate balance billing, in adequate resolution of overpayment, lack of integrity and computer systems, tell your to maintain confidentiality of information, knowing misuse a provider defecation numbers which results in improper billing, outpatient services rendered in connection with inpatient stays, duplicate billing in an attempt to gain duplicate payment, billing for discharge in Lieu of transfer, misuse of modifiers, billing company incentives that anti-kickback statute or other similar federal or state statutes and regulations, joint ventures, routine Waiver of co-pays and billing third-party insurance only, and discounts and professional courtesies
How do you know CERT programs evaluate claims
CERT Evaluates a statistically valid random sample of claims to determine if CMS was paid properly under Medicare coverage coding and billing rules.
What are the categories under exposure determination
Category 1 - healthcare workers classified as at risk for possible occupational exposure to blood-borne pathogen's HCV and HIV. Category 2 - those healthcare workers whose jobs do not involve exposure but employment may require performing a task that evolve contact with blood or bodily fluids. Category 3 any healthcare worker who's job duties do not involve exposure to blood body fluids
What are the penalties For breach of protected health information
Category 1) covered entity did not know the violation and would not have known through the exercise a reason not diligent each violation is $100-$50,000, category 2) violation was due to reasonable cause each valuation is $1000-$50,000, category 3) covered entity demonstrated will look for the Glatt, combat corrected the violation violation is 10,000 to 50,000 category 4) the covered entiry willful neglect And did not correct violation minimum $50,000
Primary safety concerns a medical setting include blood-borne pathogen's, radiation, biohazard waste, and?
Chemicals
How do CERT evaluate claims?
Claims are reviewed nationally, by a contractor, by a service, by provider type
What are designated health services?
Clinical laboratory services physical therapy services and home health services
Designated health services include
Clinical laboratory services, physical therapy services, radiology services, radiation services, parenteral and enteral nutrients, prosthetics and orthotics, home health services, outpatient prescription drugs, in an outpatient hospital services
Under the ACA of 2010 care was updated to include
Covers preventive care at no cost to you, protect your choice of doctors, remove the insurance company barriers to emergency services.
What events are reportable to OSHA
Death, days away from work, restricted work or transferred to another job, medical treatment beyond first aid, loss of consciousness, is significant injury or illness diagnosis by physician or other healthcare provider
Health information does not identify an individual is called?
Deidentified information
Definition of deliberate ignorance
Deliberate ignorance means that the provider has deliberately chosen to ignore the truth or falsity of the information on the claim submitted for payment even though the provider knows or has noticed that the information maybe false
Define deliberate ignorance
Deliberate ignorance the information which may reveal the falsity of the information submitted to the Government
Which government department is is comprised of thousands of employees Who enforce the nations federal criminal laws and help to develop and implement criminal law policies?
Department of justice
What needs to be included in exposure control plan?
Determination of employee exposure, implementation of various methods of a good exposure control, hepatitis B vaccines, postexposure evaluation and follow-up, communication of hazards to and training, record keeping, procedures for evaluating circumstances surrounding an exposure incident
Under CIA what is the term and scope
Determine scope of the CIA identifies the length of the agreement which typically is five years the link of the agreement to determine by the severity violation or violations. The CIA will include definitions to explain the scope of coverage of the CIA.
LCDs and NCDs provide information for coverage limited to what
Diagnosis codes
When billing incident to the provider does not have to be physically present in the patient's treatment room while the services are provider, but the provider must provide what
Direct supervision and be present in office suite
Some of the biggest PHI violations is reported to HHS involved?
Doctors
Of a liability under the anti-kickback statute ultimately turns on a parties intent, it is possible to identify arrangements of practices that may be present a significant potential for abuse. Which of the following questions would be helpful to determine whether a proposed action could violate the anti-kickback statue
Does arrangement or practice have potential to improve clinical decision-making?
Which of the following events would require the practiced update their CLIA certificate information within 30 days
Dr. Hansen is part of a small medical group with Dr. Miller and three physician assistance Dr. Miller is your training leaving the practice. Dr. Hansen is listed on the CL I a certificate as the owner and medical director.
Examples of unlawful contact under the anti-kickback statute
Dr. X excepted payments to sign certificates of medical necessity for durable medical equipment for patient she never examined. To home health agencies disguises referral fees as salaries by paying referring phyisicans for Dr. X's services that she never rendered to the medicare beneficiary or by paying doctor X a sum of excess of fair market value more for services she rendered under to the Medicare beneficiaries
Which federal government department is the OIG not responsible for overseeing?
Drug enforcement agency
What is EMTALA?
EMTALA is the statute that was included in consolidated Osman reconciliation act of 1985. This act is in response to increasing concern is that hospitals were denying emergency care to indigent are uninsured patients known as patient dumping.
Requirements of on call physicans under EMTALA
EMTALA requires hospitals to maintain a list of positions you're on call hospitals must have policies to address unavailability of certain specialist and physicians on call.
What is compliance?
Either a state of being in accordance with established guidelines, specifications, or legislation or the process becoming so
What is the employee retirement income security act known as ERISA?
Employment retirement income security act of 1974 protects retirement assets of employees and beneficiaries by implementing rules that qualified plans must bow to ensure that the plans fiduciaries misuse plan assets.
What would require higher level of disinfection
Endoscope
What are engineering controls under blood-borne pathogen standard
Engineering controls remove the hazard from the workplace or create a barrier between the worker and a hazard
What does that Americans With Disabilities Act of 2008 State
Every effort should be made to provide reasonable accommodations for any employee with disabilities.
Why should compliance officers that disciplinary policy's for noncompliance?
Every employee should know the consequences for noncompliance of set policies
What is fraud enforcement and recovery act of 2009 also known as FERA
FERA expands the grounds for liability under false claims act it extends a liability to any person who not only presents, or causes to be present, a false or private claim for payment or approval, and only makes uses or causes to be made by use a false record or statement material, conspires to commit a violation of subparagraph knowingly makes uses of to be made a false record of material. The revision of the FCA expense liabilities for government and property if the claim was presented to the official the government has custody of the money or property the person entity specifically tended to defraud the government.
Providers who fail to refund over payments may be subjected to prosecution under which act
False claims act
Which federal regulations are pertinent to billing companies
False claims act, health insurance portability and accountability act, patient protection and affordable care act, Infared that collection practices act
Billing companies written policies or procedures should reflect current
Federal and state statutes
What responsibility do healthcare providers have to federal healthcare programs?
Federal healthcare providers have a duty to reasonably ensure that the claim submitted to Medicare and other federal healthcare programs are true and accurate
What law does not require nursing facilities conduct state FBI criminal background checks?
Federal law
Compliance officer does not have to be a lawyer, but your chances of implementing a successful compliance program increases when you are familiar with?
Federal regulations
What are federal sentencing guidelines
Federal sentencing guidelines or rules that set out in uniform sentencing policy for individuals and organizations convicted of felonies and serious class a misdemeanor's in the United States federal court systems. The guidelines do not apply to less serious misdemeanors
Define electronic fraud or wire fraud
Federal wire fraud covers any criminal fraudulent activity that is determined to evolve electronic communications of any kind the cetacean specifically states whoever having device or intending to divide in this game or are artifacts or to the fried or obtaining money or property by needs a false or fraudulent precedences, representation and or promises transmits or causes to be transmitted by means of wire radio television communication or in interstate before in commerce.
Areas to consider for improper inducements?
Financial arrangements with outside entities to home practice may refer federal healthcare program business, joint ventures with entity supplies goods or services to physician practice or its patients, consulting contracts or medical directorship, office and equipment leases with entities to which the physician refers, soliciting and excepting or offering any gift or gratuity for more than nominal value to or from those who may benefit from the physician practice referral
OIG compliance program guidance acknowledge patient care as
First priority of a physician practice
What log from OSHA does the sharps log need to be completed on
Forms 300, 300A and 301
Dr quack just completed a 15 minute psychiatric a valuation for his patient. He intentionally completes a super bill for 30 to 45 minute session. Dr. Kwak maybe liable for
Fraud
Welfare benefit plans include
Fringe benefits
Services first in teaching settings are paid under the Medicare physician fee schedule if the services are
Furnished by a medical student when a teaching position is providing direct supervision during the critical or portions of the service
Hitech provision significantly increase the penalty amount for secretary may impose for violations of
HIPAA
what can be an effective support system of desired organizational culture
HR policies and procedures
The OIG is a division of which agency?
Health and human services
A fraudulent healthcare claim does not accurately represent the service rendered to the patient. Purposely charging or manipulating information on the medical claim, such as the date of service, or the treatment that was given, purely for financial gain, is considered what
Healthcare fraud
What is the purpose of healthcare fraud and abuse control program
Healthcare fraud and abuse control program under the joint direction of the attorney general and the secretary of HHS, acting through the department inspector general. The HCFAC program is designed to coordinate federal state and local law-enforcement activities with respect to healthcare fraud and abuse.
An effective compliance program can
Help create financial success customer loyalty community support and employee satisfaction
Under the Medicare program what are the key divisions
Hospital in inventory policy group, chronic care policy group, provider billing group, Medicare contractor management group, and provider communications group
What are examples of anti-kickback violations
Hospital providing rental rates below fair market value to physician who refers business to the hospital. Routine waiver of copayments or deductibles for patient under Medicare part B. It drug or equipment supplier providing incentives to a provider who promotes their product. If edition who is paid exorbitantly for speaking engagements by a company to home the provider for his business.
Which entity below could not bill for medically unnecessary services?
Hospitals
The purpose of an EMTAla is to prevent
Hospitals from rejecting patients in a discriminatory manner by, refusing treatment, or transfer patients to charity hospitals or county hospitals because they are unable to pay
Which agencies oversee ERISA
IRS, the DOL, and pension benefit guarantee Corporation.
Example of unlawful advertising
If a provider advertises that he is both a Medicare and Medicaid provider this is a violation and a fine $ 5000 to $25,000 if the case is at the broadcaster telecast for each. Providers are not allowed to advertise any symbols labels of healthcare administration in any manner
When can a patient instruct their provider not to share information about their treatment with their health plan?
If when scheduling an appointment, the patient indicates he or she is paying cash for the visit and does not want his or her information to be given to the healthplan.
What are exceptional situations under HIPAA
Imminent threat of life, State health agencies require providers report to them when patients have certain communicable diseases, the FDA requires providers report certain information about medical devices that break or malfunction, physicians and other caregivers you suspect child abuse or domestic violence, according to state law enforcement has the right to request information about patient. if they are suspects in a criminal investigation , the courts have rights to order providers release patient information
After an audit reveals areas for improvement, what is the next step a compliance officer should take?
Implement corrective action plans
What are administrative safeguards?
Implement policies and procedures to prevent detect contain incorrect security violation include risk analysis, risk management, sanction policy, security management processes.
What are technical safeguards?
Implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons are software programs of been granted access. This means assigning access levels in maintaining policies and procedures and ensure that these are followed. Technical safeguards include user unique identification, Emergency access procedure, automatic Log off encryption and decryption
What is the most important aspect of a Compliance program?
Implementation
Under CIA what our implementation an annual reports including
Implementation annual parts includes information of the type of reports to be submitted on implementation of the CIA and the duration of the agreement. It is the quality of these reports that will determine if a provider continues through the term of the CIA or OIG will exercise his right to post sanctions, including zip related penalties and program exclusion, for breachment
What are the seven elements of an effective compliance program for billing companies
Implementing written policies procedures and standards of conduct, identify a compliance officer and compliance committee, contacted effective training and education, developing effective lines of communication, and forcing standard through well-publicized guidelines, conducting internal monitoring and auditing, responding promptly to deducted offenses and develop corrective action.
Non-retaliation
In policies, this refers the protection against retaliation adverse action taken because an individual has engaged in protected activities threats of retaliation, discharge, or discrimination including discrimination in compensation or terms and conditions of employment
Safeharbor space rental
Includes written agreement, all space rented for the term of the agreement is identified, specific access if periodic intervals of time, term of at least one year, aggregate rental is set in advance is consistent with fair market value in arms transactions and it's not determine any manner that takes into account the volume or values of any referrals, aggregate space rented does not exceed that which is reasonable and necessary to come push the current reasonable business proposal of the agreement
What is independent monitoring under the CIA
Independent monitoring specifies the details of independent review organization IRO most CIA require, as well as the responsibilities of the providers towards the IRO.
Under the balance budget act of 1997 what was created as additional penalties in violation of healthcare fraud and abuse laws?
Individuals or entities that are found in violation of illegal renumeration anti-kickback we now face up to $50,000 in civil penalties per and up to three times amount of renumeration found in illegal activity. The balance budget act also creates penalties for persons or entities that are found doing business with an individual or entity they should've known was excluded from the federal healthcare program. The BBA also gave beneficiaries are right to receive item my statement from their healthcare providers beginning January 1,1999
Examples of safe harbors
Investments in large publicly held healthcare companies, investments and small healthcare joint ventures, space rental, equipment rental, personal services of management contracts, sales are returning physician practices to other physicians, referral services, warranties, discounts, employee compensation, group purchase organizations, waivers of Medicare part a and patient cashiering amount, increase coverage, reduce amounts or reduced premium amounts to beneficiaries, price reductions offered to help and by providers, investments in amatory surgical centers, joint ventures in underserved areas, practitioner recruitment in underserved areas, sales of position practices to hospital in underserviced areas.
Because the changing nature of healthcare regulation, the compliance program
Is continually at work and progress
What is the description of unlawful conduct?
It is a crime to knowingly and willingly execute or attempt to execute a scheme to defraud any healthcare benefit program or to obtain money or property from a healthcare benefit program through false representation
There are many benefits of having an effective compliance program. One such benefit is
It shows the practice is making a good-faith effort to be compliant
How does a GFCI function
It was shut off in the event of a ground fault
What does the OIG term as a reportable event
It's a potential overpayment, a matter that is responsible person would consider probable violation, civil or in monetary of laws applicable to any federal healthcare program, the appointment of contracting with an eligible person, the filing a bankruptcy petition
What is a joint venture
Joint venture is a business arrangement in which two or more parties agree to the pool their resources for the purpose of accomplishing this pacific task. This task can be viewed as a new project or any other business activity. In a joint venture each other participants is responsible for profits, losses, and cost associated with it. However the venture is it an into tea, separate and apart from the participants others business interests
Under the ACA cost limitations were established what are they
Lifts life time limits on coverage reviews premium increases and helps you get the most from your premium dollars
How do Medicare administrative contractors use CERT information
MAC primarily use error rates produced by the CERT program in vulnerabilities identified through the RAC audit program to identify where to target improper payment prevention efforts
What is the error rate reduction plan
MAC's follow the error rate reduction plan, which are initiatives to develop providers to comply with the rules these include: 1) targeted provider education to items or services with the highest in proper payment. 2) pre-payment and post payment claim review targeted to those services with the highest improper payments. In addition to order to encourage provider to submit clean claims correctly. 3) new or revised local coverage is determinations, articles or putting instructions to instruct providers and understanding how to correctly submit claims and under what circumstances the services will be considered reasonable and necessary.
List the Medicare administrative contractors and private payers?
Macs include Medicare drug integrity contractors, program safeguard contractors, zone program integrity contractors, recovery audit contractors, Medicaid integrity contractors, and audit MIC
Any healthcare fraud scheme that disseminate any article or document through a common mail carrier may be the basis for a charge of
Mail fraud
If doctor who fails to respond to an emergency to ration when she is assigned as an on-call physician may
Maybe in violation of EMTALA and may subject yourself in the hospital to a penalty
What is Medicaid fraud control units?
Medicaid fraud control units investigate and prosecute Medicaid provider Fraud as well as patient abuse or neglect in healthcare facilities and board and care facilities.
Which entity provides benefits integrity investigations based on billing abnormalities identified by data analysis or allegations of fraud and abuse, as well as contacts reviews that will allow them to compare billing of Medicare claims to Medicare claims known as Medi-Medi program that helps identify fraudulent activity between the two programs?
Medicaid integrity contractors
Medicaid integrity contractors are
Medicaid integrity contracts or higher to audit Medicaid providers. The Medicaid integrity contractor can do any provider, including physician groups and managed-care entities. The providers are selected based on data analysis done by other contractors or approved by state agencies. Then Medicaid integrity contractor can audit a Medicaid provider throughout the country.
Which act of 2003 Gable mentioned to electronic prescribing movement, and was put in place to reduce the medication errors due to illegible physician hand writing?
Medicare Modernization Act
What is the role of Medicare fraud strike force teams?
Medicare fraud strikeforce teams harness new technologies and combined resources of federal, state, and local law-enforcement entities to prevent and the come back healthcare fraud, waste and abuse.
Under Medicare secondary payer the Medicare statute or regulation requires all entities bill Medicare for items or services rendered to Medicare beneficiaries must determine whether?
Medicare is the primary payer for items or services
Psychotherapy notes do include
Medication prescription monitoring, counseling session start and stop times, the modalities and frequencies of the treatment for results of clinical test, any summary of the following items diagnosis functional state treatment plan symptoms prognosis in the progress to date.
What is the key concept of the privacy rule?
Minimum necessary
What is auditing and monitoring?
Monitoring is an ongoing process of reviewing the operations as they occur in the present. Auditing consists of contacting reviews of risk areas you turn in compliance with the legal requirements. And I don't provide a snapshot of compliance at a specific point in time, often in the past.
After hiring, how often should provider check to make sure employees are not on the OIG list of excluded individuals?
Monthly
Compliance programs are
More dangerous if they are developed but not implemented
Is a patient entitled to all information retained in the designated record set?
No an individual has no right of access to the following information psychotherapy notes, information compiled in a reasonable anticipation of or for the use of civil, criminal, or administrative action or proceeding, PHI maintained by a covered entity that is, subject to all CLIA to the extent of provisions of access to the individual would be here prohibited by law, if the laboratory is exempt from CLIA
How do you CERT programs categorize improper payments
No documentation, insufficient documentation, medical necessity, incorrect coding
When creating handicap parking spaces, which is true with regard to four or less spaces?
No handicap sign is required as long as there is an access Aisle
What policy is written to encourage communication?
Non-retaliation policy
What are the record and document retention terms under CIA
Not withstanding the documentation requirements of the Healthcare provider records, that OIG requires documents relating to the CIA be kept one year after the term of the CIA
Which office provides guidance to healthcare industry in the form of an advisory opinions, special fraud alerts, special adviser bulletins, and compliance program guidance?
OIG
What can providers view that will help them understand the compliance requirement of a clinical lab?
OIG clinical lab guidance
What is a corporate integrity agreement
OIG negotiate corporate integrity agreement with healthcare providers and other entities as part of the settlement of federal healthcare program investigations arising under a variety of civil false claims statute.
What federal agency is in charge of employee safety?
OSHA
What is OSHA and what do they do
OSHA is one of three agencies created by occupational safety and health act of 1970 they ensure safe and healthful working conditions for working men and women by setting and enforcing standards and providing training such as out reach education and assistance. OSHA is part of department of labor and human health services
Sue works for ABC family physicians. The providers at this office ask her to research the department that helps protect patients from unfair treatment or discrimination. What department or agency would this be?
Office for civil rights
Which department is the largest inspector in the federal government
Office of Inspector General
What other parking requirements are required under ADA
One of every six faces must be made van accessible. Small businesses with limited parking do not have to post signage however there must be one handicap accessible parking space for both disabled employees and patients.
What are the most common reasons for improper payments
One payment is made for services that do not meet medicare coverage and medical necessity criteria, payment is made for services that are incorrectly coded, payment is made for services where the documentation submitted does not supported by the ordered service
What are statutory bars under qui tam?
One the relater was convicted of a criminal conduct arising from his or her role in the NFC a violation. To another action concerning the same contact has already been filed. Three the government related party to a symbol or in ministered of money proceeding concerning the same contact. For the action is based on the information that is disclosed to the public through any several means criminal civil or a ministry periods in which the government is a party, government hearings, audits, reports or social media or through news media.
If a physician practice uses another entity standard of contact they must
Only select those standards that represent a high-risk issues for the practice
The RICO act is a law that increases the severity of penalties for violations of what?
Organize crime
Skilled nursing facilities or Medicare certified facilities that provide extended skilled nursing or rehabilitative care under Medicare part
Part A
What are forms of PHI
Patients name streets city county ZIP Code, dates directly related to patient including birthdate admission date discharge date and date of death, telephone numbers and fax numbers and email addresses, Social Security numbers medical record numbers, health plan beneficiary numbers account numbers, certification of license numbers, vehicle identified and serial numbers, including license plate numbers, device identifier serial numbers, web universal law resource locator is, Internet protocol, biometric identifiers, full face and photographic images, any unique identifier number or characteristic are code any medical history
What plans are covered under ERISA
Pension benefit plans and welfare benefit plans
Defined pension benefit plans
Pension benefit plans cover all retirement benefit plan such as profit-sharing plans, money purchase pension plans, 401K plans, cash balance, defined pension plans, target benefit, employee stock options plans, stock bonus plans sept Ira's, and simple Iras
What is one way to discourage whistleblower?
Performance reviews
Which serves as a reference source of information about personnel policies and procedures?
Personnel policy manual
What are physical safeguards?
Physical measures policies and procedures that protect a covert into teeth electronic information systems and buildings and equipment from natural and environmental hazards of on authorized intrusion.
To ensure the Medicare does not incorrectly reimburse the physician for overhead portion of the payment if the service was performed in the facility setting, it is important to have what on the claim
Place of service
Which of the following is considered the primary means of minimizing employee exposure?
Policies and procedures
What does part D cover
Prescription drugs
What defines and limits the circumstances in which an individual's PHI may be used or disclose by covered entities?
Privacy rule
The ZPIC were previously known as?
Program safeguard contractors
According to the federal sentencing guidelines to have an effective compliance and ethics program an organization shall exercise due diligence to detect criminal conduct. The FSG's also state organizations shall
Promote an organizational culture that encourages ethical conduct and commitment to a compliance with the law
How long do providers have to supply records for CERT?
Providers have 75 days to supply medical records to CERT
What is qui tam action
Qui Tam action is a powerful weapon against healthcare fraud because a private party with independent knowledge of wrongdoing may initiate the action. Any person can file. The complaint must be filed with federal district court under seal. The complaint and written disclosure which contains all relevant information at the time of filing the complaint.
How far back can RAC go to review claims and for what types of services
RAC are permitted to review any medical claims paid prior to October 1, 2007, and may review the last three years a provider claims for the following types of services. Hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory, durable medical equipment.
RACS perform what type of reviews?
RAC perform automated and complex reviews
The documentation of each patient encounter should include
Reason for the counter and relevant history, physical examination findings and prior diagnostic test, assessment, clinical impressions or diagnosis, plan of date and legible identity of the observer
What is meant by reckless regard
Reckless regard means that the provider pays no regard to whether the information on the claim submitted for payment is true or false. an example of a provider who submits a false claim with reckless regard would be assigns the billing function to an untrained office person without inquiring about whether the employee has the requisite knowledge and training to actually file such claims
What are recovery audit contractor used for
Recovery audit program is used to detect incorrect improper payments in the Medicare fee-for-service program and provide information to CMS and medical review contractors that help protect the Medicare trust funds by preventing future improper claim payments.
Regulated Waste is the found with the following labels and colors
Red indicates flammability hazard, blue indicates health hazard, yellow indicates reactivity hazard, white is special information
Under EMTALA, all participating hospitals are required to provide at least a medical screening exam to a patient who comes in should emergency department
Regardless of the patient's insurance or ability to pay
In order for a compliance program to be effective, it will need to be
Regular reviewed and updated
Employee should be told that if they are question about an investigation they had the right to do what?
Request an attorney
What should not be ignored and may require necessary policy measures to prevent avoidable reoccurrence
Risk areas
Examples of safe harbors
Safe harbors include investments in ambulatory surgical centers, joint ventures in underserved areas, practitioner recruitment in underserved areas, sales a physician practices to hospitals in underserved areas, subsidiaries for obstetrical malpractice insurance in underserved areas, investment in group practices, specialty referral arrangements between providers, cooperative the hospital service organizations
If a referred patient to your practice has a hearing deficit and needs an appointment, what steps is your practice take when scheduling?
Schedule the appointment if you days ahead and make arrangements for an interpreter
And emergency condition is defined as having symptoms including severe pain and psychiatric disturbances such as that the absence of immediate medical attention could result in
Serious impairment of bodily functions, and or Serious dysfunction of any bodily the organ or part
Reasonable accommodations under the ADA include
Service animals, wheelchairs, communication, existing facilities element by element safe harbor, readily available barrier removal, parking, accessible entrances, and staff training
How many elements are required to have a successful compliance program
Seven
What are the requirements for transfers under EMTALA?
Several requirements must be met before transferring and unstable patient. One the consent of the receiving hospital must be obtained. To the patient's condition must be documented. The physician must attest in writing that the medical benefits expected at the receipt and physically outweigh the risk of the transfer.
What does the HHS OIGsuggest as possible warning signs that noncompliance may exist?
Significant change in the number of types of clean rejections.
How long does a privacy rule state medical practice and covered entity need to retain medical records?
Six years
Psychotherapy notes
Special care is given to psychotherapy notes. These notes should be how separately in the medical record and should have closely monitored user access. Insurance contractors are not to request psychotherapy notes. CMS states that physically integrating information excluded from the definition of psychotherapy notes and protected information into one document or record does not transform the nonprotected information into protected psychotherapy notes.
Teaching physician requirements
Special regulations applying to teaching phyisican. Billings regulations provide that service is provided by teaching visit in teaching settings are generally payable under the physicians fee schedule only if the services are personally furnished by the physician who is not the resident or the services are furnished by resident in the presence of a teaching physician.
Compliance training education should include
Specific government and private payer reimbursement policies and principles, proper documentation of services rendered including the correct application of the visual rules and guidelines, signing a form for a position without the physicians authorization, did you to report misconduct
During an internal investigation, what is the next step after regulatory scope and applicable Are researched?
Start pulling records for review
What is an example of using the process of complete elimination or distruction of all forms of microbial life?
Sterilization
Employee should be told that, if there question in an investigation they should always what?
Stick to the facts and don't speculate
The OIG defines the term reportable event in its CIA by noting that it could be the following
Substantial overpayment, it matter that is reasonable person would consider a probable violation of criminal, civil, administrative laws applicable to any healthcare program for what penalties are exclusion maybe authorized, employment a contracting with an ineligible person, the filing a bankruptcy petition
What needs to be included on the successor liability under the CIA
Successor liability are changes to locations are business obligations under the CIA to make reports whenever they have a new business unit or location for furnishing items providing federal healthcare program
Modifier 25 Is used to allow additional payment for EM services performed by provider on the same day as a procedure as long as?
That EM services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure
What authority does that OIG have
That OIG has the authority to seek civil monetary penalties, assessments, and exclusion against an group or individual based on a wide variety of prohibited conduct. The criminal and civil enforcement actions related to the OIG's investigative and legal work in the legal action by the DOJ.
CMS self referral for disclosure protocol set forth a process for providers of services and suppliers to self to close actual or potential violations of physicians of referral statue which of the following statements are true about SRDP?
That SRDP is intended to facilitate the resolution add only matters that, in the disclosing party is reasonable assessment or actual or potential violations of the physician several statute
The patient protection and affordable care act of 2010
The ACA was passed by Congress and then a signed into law by the President on March 23, 2010 and on June 28, 2012 the Supreme Court render a final decision to uphold the healthcare law
What is comprehensive error rate testing program
The CERT program is to establish error rates and estimates of improper payments in compliance with improper payment elimination and recovery improvement act known as IPERIA. CMS took over improper payment measurements in 2001 and reported the first and improper payment rate in November 2003.
Which of the following is documentation guideline that will help an organization avoid overpayment demands and potential false claims act violations in the event of an audit by a third-party payer?
The CPT and diagnosis code reported on the health insurance claim for billing should be supported by documentation in the medical record
Penalties for not filing government reporting for retirement plans
The IRS, DOL, and the PBGC all have separate penalty assessment 1) failed to file a return back to $50 a day is that IRS penalty and up to that $1100 a day under the DOL and a $1100 a day under the PBGC penalties. Criminal penalties up to $5000 for an eventual and $100,000 per appointment plus imprisonment up to one year are possible for willful violation
What is the Medicaid integrity program
The Medicaid integrity program under the Social Security act directed by CMS to enter contracts to review Medicaid provider actions on it claims, identify overpayments and educate providers and other on the Medicaid program issues
What is Medicare program integrity
The Medicare program integrity is to achieve the goal of improving provider compliance and lowering the error rate. there's three parallel strategies that are followed. Strategy 1 Preventing improper payments through Mac and SMRC evaluation of program vulnerability and taking the necessary action to prevent the identified going to vulnerability in the future. 2 correcting past improper payments your post payment claim review by the RAC auditors. 3 measuring improper payments and pinpointing the causes for the improper payments by calculating service specific, provider type in contract specific error rates by the CERT contractors.
Which offices main responsibility is to investigate healthcare fraud, waste, and abuse?
The OIG
The role of the OIG and investigations is?
The OIG is another agency involved in investigations in enforcement of healthcare fraud. The OIG and other state and federal agencies collaborate to ensure civil, criminal, or administrative action is taken against providers who break the laws governing federal healthcare programs.
What is the OIG's position regarding gainsharing?
The OIG's position that the civil monetary penalty's law clearly prohibits any gainsharing arrangements that involve payments by or on behalf of of a hospital to physicians with clear responsibilities to induce a reduction or limitation of services to Medicare or Medicaid beneficiaries
What is racketeer influenced and corrupt organization act also known as RICO
The RICO act is a law that increases the severity of penalties for violations involving organize crime. The last day for any person or group who commits you need two of the list of 35 crimes known as racketeering activity within a decade can be determined and committed to similar result of similar intentions when we charge with racketeering. This covers such as bribery extortion money laundering counterfeiting gambling murder arson robbery kidnapping harboring certain out legal aliens obstruction of justice slavery and others
Once the ZPIC detects, investigate and gathers evidence of suspected fraud and abuse what happens next
The ZIPc hands over the information to OIG for criminal or civil prosecution
What set ZPIC audits apart from Medicare audits?
The ZPIC are private companies contacted by CMS, used to conduct audits for Medicare and Medicaid over payments
Routine waiver of co-pays would be considered a violation of which law
The anti-kickback statute
What is the blood-borne pathogen standard
The blood-borne pathogen standard was created in 1991 because of significant risk associated with exposure to viruses and other microorganisms that cause blood borne diseases. Of the primary concern of HIV and hepatitis B and C viruses.
Under the CIA what is in the corporate integrity obligations
The corporate integrity obligations cover the elements of compliance program guidelines or federal sentencing guidelines, identifying the content and the person is obligated to ensure compliance of the program integrity program.
What elements are required to be Convicted for mail fraud
The defendant must have been engaged in a scheme to defraud, the ski must haven't bought material mistake meant or omissions, the skiing resulted, or would have resulted upon completion, in the loss of money property or on the services, the defendant must have use the use of US mail in for their scheme to defraud.
What is included in the disclosure program of a CIA
The disclosure program component of the CIA spells out the details of the disclosure program that would include a toll-free number and not retaliation and other policies.
What is covered under the social security act of 1935?
The elderly, children and the handicapped
Definition of false claims act
The false claims act prohibits knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval. Additionally it prohibits knowingly making or using or causing to be made or use a false record or statement to get a false or fraudulent claim paid or prove by the federal government or its agents like a carrier other claims processor or state Medicaid programs
False claims act
The false claims act provides in pertinent part, that anyone who knowingly present, or causes to be presented, to the government a false or fraudulent claim for payment or approval is liable for the civil penalty of not less than $5000 and not more than $10,000, +3 times amount of damages. While the False claims act imposes liability only when the Claimant asked knowingly, it does not require that a person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless regard or deliver ignorance of the truth or falsity of the information, also can be found liable under at 31 USC. In sum, the false claims act imposes liability on any person who submit a claim to the federal healthcare program or she knows is false. Anti-fraud efforts return approximately eight dollars for every dollar invested in the federal enforcement activities
What is the office of Inspector General
The federal agencies mission is to protect the integrity of the participants as well as health and welfare a program beneficiaries. Since it's 1976 establishment, OIG has been at the forefront of the nations efforts to fight waste, fraud, and abuse and Medicare Medicaid.
what is physician liability under EMTALA?
The following three provisions apply to physicians. Section 1395 DD imposes a penalty on the physician who fails to respond to an emergency situation when he she is assigned as the on-call position. The position who signed the certificate in support of an appropriate transfer as detailed in section is liable if he she knows that the certificate was false. Provides direct liability if physicians working at hospitals and there might be special obligations imposed on to those hospitals. It is the presumption that only this section only applies the physician about the violation.
Under what circumstances can a relator not file or pursue a QUI tam action
The government is already a party to a civil or ministered of money proceeding and the action is based upon information that has been disclosed to the public
How many regional CMS offices are there
The main headquarters in Baltimore Maryland, with 10 regional offices around the country
What are questionable features of joint ventures
The manner in which investors are selected and retain, the nature of the business structure of the joint venture, the financing and profit distributions
Under the RICO act what is the maximum penalty and fines
The maximum penalty is for racketeering include a fine up to $25,000 and up to 20 years in prison. In addition to the forfeit of all business interest in games gleaned from the criminal activity.
Self referral
The physician self referral act, also known as Stark law, governs the practice of referring a patient to receive a service office visit a facility in which the physician has been answered interest. For example if physician maybe part owner of a hospital or imaging center. If the visit she refers patients to the facility/center he or she may be in violation of the physician self referral act
Define risk
The potential of losing something of value, an action against the potential to gain something of value. Values, social health, social status, emotional well-being or financial wealth can be gained or lost when taking risk resulting from a given action activity and or in action, forcing or I'm for seen. Risk can also be defined as intentional interaction with uncertainty. Perceived perception is a subjective judgment make people about the severity of a risk.
Under the CIA what is in the preamble
The preamble establishes the statutory basis for the CIA and the date it was first entered it includes the statement of the CIA is intended to promote compliance with the statutes, regulations and written directives of Medicare, Medicaid, and the other federal healthcare programs.
Violation of stark that occurs when
The referring physician or immediate member of the referring physicians family has a financial relationship with the entity receiving the referral
Under Qui tam action A relator is entitled to receive how much?
The relater is entitled to receive between 15 to 25% of them that were covered by the government through the action
What are the risks with the physician documentation?
The risks are documentation is not performed timely and accurate. it is incomplete, it does not reflect appropriate documentation of the diagnosis and treatment plan
What is the purpose of the blood-borne pathogen standard?
The standards set forth requirements for employers with workers exposed to blood or other potentially infectious materials. To reduce or illuminate the hazards of occupational exposure, and Employer must implement an exposure control plan.
What needs to be included in the sharps log?
The type and brand of the device involved in the incident, location of Incident and description of incident
What is the goal of the zone program integrity contractor
The zone program integrity contractor is to identify cases suspected of fraud, investigate them, and take action to ensure inappropriate Medicare payments are recouped.
When is an outside consultant and or legal counsel necessary
There is no requirement to hire a consultant or counsel but such as is it may be beneficial during certain phases of development and if issues arise
Advanced beneficiary notices, what are the requirements?
They must be in writing, identify the specific service that may be denied with the CPT code and HCPCS are required, stay in the specific reason why the physician believes that the service may be denied, be signed by the patient acknowledging that the required information was provided and the patient assumes responsibility to pay for the service
Which is the underlying principle of equal employment opportunity while?
This law requires all persons to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law
Why is training important under OSHA
Training a significant factor to ensure OSHA compliance. It is best practice to have annual and retraining for all employees. It is also extremely important to have train management as means of creating a commitment to prevention.
PHI may be disclosed without the patients authorizations for?
Treatment payment and operations
What is record retention for OSHA
Unless otherwise stated within a particular OSHA regulation, all employees exposure and medical records must be maintained for at least the duration of the employees employment +30 years.
What term would be used for a practice that, either directly or indirectly, results in unnecessary cost to the Medicare program?
Waste
Define welfare benefit plans
Welfare benefit plans cover a broad range of Fringe benefits. This includes health, dental, Eye care, vacation, bonus, sickleave, cafeteria plans and group insurance health plans
Improper inducements
When an organization or individual offers another organization and individual and incentive for the referral of potential clients or patients. And incentive may take the form of cash, non-cash gifts, providing services for the benefit of the referral source or making reciprocal referrals.
All expenses related to developing and implementing a compliance program are considered the cost of doing business and our talks about the war for the organization except
When the expenses are a result of an imposition of a penalty
Advanced beneficiary notice should be presented when
When the service is not covered benefit of Medicare
Deficit reduction act requires the providers who have more than 5 million either received or paid to the reimbursement from the Medicaid program inform employees of their ability to?
Whistleblower action
How is the ZPIC audit initiated
Whistleblowers, probe audits, other audit agency findings, beneficiary complaints, hotline complaint, complaints and notices from other governmental programs
What is one of the main responsibilities of the CMS regional offices?
Work on quality initiatives
Can you please transfer a chemical to another container
Yes as long as a secondary container label is used in meets regulatory requirements
Are there certain goals for PHI disclosure in cases of emergency?
Yes pHI can be released for emergency treatment
Is there such thing as defective authorization for PHI?
Yes the regulations state that an authorization will be defective and that's in valid in any of the following circumstances, expiration date has passed or the expiration event is known by the cover entity to have occurred, authorization has not been filled out completely, with respect to the required element, authorization is known by the covered entity be revoked, authorization is in personable compound or conditional authorization, and material information in the authorization known by the covered and to be false.
Is it acceptable for practices to call and remind patients of their appointments?
Yes, if it is stated in the notice of privacy practices
What description best describes ZPIC?
ZPIC are private companies contacted by OIG used to conduct audits for Medicare and Medicaid over payments
What are zone program integrity contractors
ZPIC data analysis program are to identify provider billing practices and services that pose the greatest financial risk of the Medicare program
What do ZPICs target?
ZPICS target both medical necessity of the claim and coding errors
What is the maximum amount of money and employer can charge for personal protective equipment?
Zero
What is the key items that can protect a medical practice from harassment liability
Zero tolerance policy for harassment
Non-participating physicians billing practices
A physician may not bill a Medicare beneficiary $50 for an office visit when the Medicare allowable for a charge for the office visit is $25. failure to comply results in a fine up to $10,000 per violation or exclusion from participating in federal healthcare programs up to five years
A safeguard the security officer put in place is that all employees were given name tags to wear while on duty. Policies put in place to restrict access to employee area. Policies were also written to establish proper use of computer work station for business and antivirus software was added. What type of safeguard does this action describe?
Administrative safeguards
For embezzlement in connection with healthcare
An office manager for Dr. X knowingly embezzled money from the bank account for Dr. X's practice. The bank account and reimbursement received from Medicare program that's intention embezzlement of funds from this account is a violation of the law
What are the biggest risks with coding and billing?
Billing for services not rendered or provided by as claimed, submitting claims for equipment medical supplies and services that are not reasonable and necessary, double billing resulting in duplicate payments, billing for noncovered services as if covered, knowing misuse of a provider identification numbers which results in improper billing, unbundling billing for each component of service instead of billing for all inclusive code, failure to properly use Coding modifiers, and a coding the level of service provided
The HIPAA a security rules require covered entities to put safeguards in place to protect personal health information. A medical facility hardy security officer who had done a risk analysis to identify potential rest of the computer system. He has implemented policies and procedures on a computer access and password management.
Technical safeguards
What should be included in billing and coding training?
Coding requirements, clean development and submission process, signing a form for a physician without physician authorization, proper documentation of services rendered, proper billing standards and procedures for submission to accurate bill for services to federal healthcare program beneficiaries, the legal sanctions for submitting deliberate false a reckless billings
What steps are required to responding to detected offenses?
Corrective action plan, the return of any overpayments, a report to the government, and or a referral for law-enforcement authorities
Having the ability to respond to issues enables a practice to develop effective action plans to correct problems and prevent future problems from occurring what is one step that can be taken to establish compliance effectiveness for responding to and or preventing compliance issues?
Creating prevention team, consisting of representatives from compliance, audit, and any other relevant functional department.
Examples of obstruction of criminal investigations of healthcare offenses
Dr. X instructors employees to tell the OIG investigators that doctor asked personally perform all treatments when in fact the medical technicians do majority of the treatment and Dr. X rarely present in the office. 2) Dr. X was under investigation by the FBI for reported fraud in Billings. doctor X altered the patient records and attempt to cover of improperties. Example for this penalty of a fine and imprisonment of the five years
Examples of civil monetary penalties
Dr. X paid Medicare and Medicaid beneficiaries $20 each time they visited him to receive services and have *TEST perform that we're not preventative care and Test. 2) Dr. X's asks his physician assistant Pete to provide services to Medicare and Medicaid beneficiaries without confucting a background check and Pete had per been on the OIG exculsions list. 3) Dr. X has his oximetry company build Medicare for pulse oximetry that he knew he did not perform and the services have been intentionally up-coded
Examples of under Stark law
Dr. X worked in a medical clinic located in a major city. She owned a freestanding laboratory located in a major City. Dr. X referred all orders for laboratory tests on her patients the laboratory she owed. 2) Dr. X agreed to serve as a medical director on the home health agency for which he paid a some substantially about their monetary value for his services in return Dr. x routinely referred his Medicare and Medicaid patients to the home health agency for health services. 3) Dr. White receive your monthly stipend of $500 for a local hospital to assist him in meeting prep practice expenses Dr. White performed no specific service for the stipend and had no obligation to repeat the hospital Dr. wire for patients the hospital for inpatient surgeries
According to the federal register, though Oig has a listed number of potential risk areas for physician practice. This risk areas include coding and billing, reasonable and necessary services, and documentation. Which of the following scenarios would be considered a risk or areas for position practice?
Dr. Y bills Medicare using a covered visit code when the actual service was noncovered annual physical this could be considered improper coding and billing in there for is considered a risk area
An example of mail and wire fraud
Dr. x knowingly submitted Repeatedly submit electronically as to Medicare carrier for office visits that he did not actually provide to Medicare beneficiaries with the intent to obtain payments from Medicare for services he never performed. 2) Dr. X in urologist knowingly submitted claims for tests that we're not reasonably unnecessary and intentionally of upcoded office visits and electromyograms to Medicare
Section 101 Medicare prescription drug, improvement, and modernization act of 2003 authorize an exception to the physician self referral Prohibition for certain arrangement in which the physician Can receive necessary non-monetary renumeration. What is this exception related to?
E-prescribing
Federal and state investigators are in the process of identifying documents that are identified in the government search warrant. Which of the following statements are true regarding the document protection?
Employee should not destroy, change or alter any documents, including paper, tape or an electronic records because such actions can lead to criminal liability.
What are the steps for auditing and monitoring evaluations
Ensure that the standards and procedures are in fact current and accurate but also whether the compliance program is working. following steps a standards and procedures review and claim submission audit
Examples of unlawful conduct
Example one doctor ask a chiropractor intentionally bills Medicare for physical therapy and chiropractor treatment that he never actually rendered for the purpose of fraudulently obtained a Medicare payments. Example to Dr. X a physiatrist bills Medicare and Medicaid and tricare in private insurances for psychiatric services that were provided by his nurses rather than himself.
What are examples of internal documentation guidelines a practice could use?
Examples of internal documentation guidelines are the medical record is complete and legible, the documentation for each patient encounter includes the reason for the encounter any relative history, physical examination, findings prior to diagnostic test results, assessment clinical impression or diagnosis plan of care and date of legible Identity of the other observer
Physician Responsibilities to hospitals under EMTALA.
First, hospital must conduct an appropriate medical screening examination to determine if an emergency medical condition exists. Second, if the hospital determines that emergency medical condition exists, it provide treatment necessary to stabilize the emergency medical condition or comply with requirements to effect a proper transfer of a patient whose condition has not been stabilized. Forth requirement if individual refuses hospital's offer of additional examination treatment, or refuses transfer. A hospital may not transfer a patient if the patient has not been stablized, Unless the patient or the representative makes a written request for the transfer to be to another medical facility after being informed of the risks to a physician has signed certification. The medical risks and benefits of a transfer and certifying that based upon the information available at the time of transfer of the medical benefits reasonably expected from the transfer outweigh the increased risks. 3) if the doctor is not physically present when the transfer decisions made a qualified medical person signs the certification after consultation with the doctor.
As the complaint contact for your position practice, you are charged with developing the policies and procedures related to coding and billing. When the company accepts this is an policies, which of the following statements should be included?
For any services bill, documentation must be present in the patient's medical record to support the services.
Examples of anti-kickback statute
For the referral of an individual to another for the purpose of supplying items or services that are covered by federal healthcare program, for purchasing, leasing, ordering arranging for any good facility service or item that is covered by federal healthcare program.
Difference between erroneous and fraudulent claims to federal healthcare programs
Fraudulent claims intentionally or recklessly are submitted to federal healthcare programs. Erroneous claims are innocent errors submitted unintentionally to federal healthcare programs
The office manager has missed placed his laptop. The hard drive on the laptop is not encrypted. Which of the following data stored on the laptop would be considered a HIPPA breach if some gains access to the laptop?
Health records of students
Under the health insurance portability and accountability act of 1996 public law 101 191 what is the name of the national program designed to coordinate federal state and local law-enforcement activities with perspective healthcare fraud and abuse?
Healthcare fraud and abuse control program
Contracts with third-party billing services?
If physician may contract with a billing service on a percentage basis however the billing service cannot directly receive the payment from Medicare funds into the bank account that it's only controls Medicare payments can only be made to either beneficiary or the party such as a physician that furnished the services
A physician practice hired a consultant to perform external audit services for their practice. After the consult began working, the OIG and GSA list were checked and it was found that the consultant was excluded from federal healthcare participation. What steps should the practice take?
Immediately ask the consultant to stop work in contact legal counsel.
Examples of safe harbors under the anti-kickback statute
Investment interest, space rental, equipment rental, personal services in management contracts, sell the practice, referral services, warranties, discounts, employee relationships, we were apart a coinsurance and deductible amounts, group purchasing organization's, increased coverage or reduced cost sharing under the risk faces on or prepaid plan, charge reduction agreements with healthcare plans
Description of mail and wire fraud
It is a crime to use the Mail private courier or wire services to practice scheme to defraud another of money or property the term wire services includes the use of a telephone **** machines or computer eat or wire services to further farther activities are considered a separate crime for incidence each physician claim submitted electronically to a carrier would be considered a separate violation per the law
What is anti-kickback statute?
It is knowingly and willingly solicit and receive offers or pay renumeration of any kind of good money or service
The federal anti-kickback statute places certain constraints on business arrangements related directly or indirectly to items or services reimbursed by any federal healthcare program, including, but not limited to, Medicare and Medicaid. According to the OIG, Which of the following would likely be an acceptable practice?
It physician practice should participate in all aspects of hospital compliance program to be sure the anti-kickback statute is not violated.
Examples of false claims act
It's visitation submitted claims to Medicare Medicaid representing that he personally perform the services when reality the services were performed by nonphysician and they were not reimbursable under the federal healthcare programs. Dr. X intentionally up coded office visit and angioplasty consultations that were submitted for Medicare or payment. Dr. ask a podiatrist only submitted claims to Medicare and Medicaid programs that were non-routine surgical procedures when he actually performs routine and noncovered services such as the cutting and trimming of toenails and removing a corns and calluses
Descriptions of mandatory exclusions
Mandatory exclusion individuals or entities convicted of the following contact must be excluded from participation Medicare Medicaid for the a minimum of five years. One criminal offense related to the delivery of an item or service under Medicare or Medicaid to conviction under federal or state law. a criminal offense related to medical neglect or abuse of a patient. 3 ) conviction on your federal or state law of a felony related to fraud that embezzlement breach of fiduciary responsibility or financial misconduct against the healthcare program finance by any federal or local government for convection understate law of a felony related to the unlawful manufacture distribution prescription or dispensing of controlled substance
A patient being seen by a physician has unpaid medical bills in an excess of $5000 after insurance payment. The patient has now lost his job and has limited financial resources. Yeah office manager reviewed the patient's financial situation to assess patient's ability to pay and has agreed to reduce the fees 02 $2500. Would this act violate the OIG gift for Allowance for beneficiaries?
No, this would be an exception to the OIG gift allowance because it is based on the patient's ability to pay
Examples of exclusions
Nurse are was excluded based on the conviction involving obtaining dangerous drugs by forgery she also altered prescriptions that were given to her for her own health problems before she presented them to a pharmacist to be filled. 2) practice excluded due to its affiliation with an excluded owner the practice, the owner excluded from participation in Medicaid Medicare and Medicaid programs for soliciting and receive it illegal kickbacks and was actively be in day-to-day operations of a practice after his exclusion
What is the penalty for unlawful conduct?
Penalty may include the imposition of fines and imprisonment up to 10 years or both if the violation result in serious bodily injury to prison term may increase to a maximum of 20 years if the violation results in death the prison term may be expanded to include any number of years or life imprisonment
Descriptions of permissive exclusions
Permissive exclusions are individuals or entities convicted of the following offenses maybe removed from the participation of federal healthcare programs for a minimum of three years. One a criminal offense related to delivery of an item a service that under Medicare Medicaid to a misdemeanor related to offense. 4) financial misconduct for interference with obstruction of any investigation into certain Offenses. 5) in misdemeanor related to unlock the manufacture distribution prescription or dispensing of controlled substance is 6) exclusion of suspension under federal or state healthcare programs seven submission of claims for excessive charges I get unnecessary services that charges fails to meet professionally standards
What is Stark law
Phyiscans and immediate family members who have an ownership investment or compensation relationship with an entity providing healthcare services are prevented from referring patients to the services were payment was made by federal healthcare program
What is the most common type of laboratory?
Physician office laboratory
Exceptions to stark law
Physician services, in office ancillary services, pre-paid claims, rental of office space rental of equipment, bona fide employment relationship, personal service arrangement, renumeration, provision of designated healthcare services, physician recruitment,inside transactions, certain physician arrangements with a hospital, payments by a physician for items and services
Dr. Amber is the emergency department physician at Orangeville Hospital. The patient arrives complaining of chest pain, dizziness, and shortness of breath for the past three hours. What is the first thing Dr. Amber should do to comply with an EMTALA?
Providing medical screening examination to determine if the patient has a medical emergency
Examples of physician incentive arrangements
Provisions of free or significantly discount billing, nursing or other staff services payment of the cost of the visit in trouble and expense it for conferences payment for physician services that require few if any substance of duties by the physician guarantees and efficient income fails to reach a predetermined level of the entity will supply the remaining up to a certain amount incentivizing physicians.
For a larger physician practices, how frequently does OIG recommend reporting compliance activities to the Board of Directors and CEO?
Regularly
Improper Inducements , Kickbacks and Self-Referrals.
Remuneration for referrals is illegal because it can distort medical decision-making, cause overutilization of services or supplies, increase costs to Federal health care
You have been identified as the compliance officer at your practice. The OIG compliance guidance for individual and small group physician practices suggest six Specific duties that may be assigned to you. What is one of those duties?
Reviewing reports to see that new employees and vendors have been checked against the origins list of excluded individuals and entities
Safe harbors under anti-kickback statute?
Safe harbors immunize certain payments and business practices that are implicated by the anti-kickback statute from criminal and civil prosecution under the statute to be protected in a safe harbor and arrangement must fit squarely in the safe harbor
As part of the practices compliance program, record retention policies and procedures should be developed. This policy and procedure should address the timeframe is associated with the retention of berries records. When developing a policy, which of the following statements should be present?
Specific records must be retained based upon the most stringent requirements identified in federal or state laws or internal policies and procedures.
Benefits of a voluntary compliance program
Speed and optimize proper payment of claims, minimize mistakes, reduce the chances that an audit will be conducted by HCFA or that OIG and, avoid conflicts with the self referral and anti-kickback statute
anti-kickback statute
The Social Security amendments of 1972 included the original anti-kickback legislation the legislation stated the statute was to prevent fraud and abuse from federal healthcare programs. A criminal statute that provides exchange of anything of value in an effort to induce or reward the referral of federal healthcare program business. If fined up to $25,000 and imprisonment up to five years
A rental of space in physician offices by a person or entity which physican referred
The agreement covers all of the space agreement and specifies the space covered . If the agreement intended to provide the lessee with access to the space for periodic intervals of time rather full-time for the term of the rental agreement, the rental agreement specifies exactly the schedule precise length of each interval. The term of the rental agreement is for less than a year. The aggregate rental charge is advance, is consistent with fair market value, with and is not determined the volume or value of any referrals or business otherwise between the parties for which payment may in whole or in part under Medicare State health care program.
What is the civil monetary penalties law
The civil monetary penalties law is a comprehensive statute that covers an array of fraudulent and a piece of activities is very similar to the false claims act. For is instance this CMPL prohibits a healthcare provider from presenting or causing to be presented claims for services that were provided that the provider knows or should know were one not provided, not medically necessary, provided by person who is not licensed, Furnished by a license provider who obtained his or her license through misrepresentation, furnished by physician who has not certified in medical specialty that he or she claimed to be certified in, furnished by physician who was excluded from participation federal healthcare program to which claims were submitted
What are the recommended record retention guidelines?
The length of time that a practice records are to be retained specified in the standards and procedures based on federal and state statute should be consulted, medical records if in the possession of practice need to be secured against loss distruction, unauthorized access, reproduction corruption or damage, standards and procedures can stipulate the disposition of the medical records in the event the practice is sold or closed
What is one method for improving quality in documentation?
The method is to compare the practices claim denial rate to the rates of other practices in the same specialty to the extent of the practice can obtain that information from the carrier. Physician coding and diagnoses distribution can be compared for each physician with the same specialty to identify variances.
Who should be involved in a claim submission audit?
The person in charge of billing and a medically trained person to audit the records
Example of an excess charges and refunding
The phyisican must refund the amount collected above the allowable charge to an individual within 30 days of a notice of violation for example if a physician collected $50 for Medicare patient beneficiary for an office visit but the limiting charges is $25 the phyisican must refund $25 to the beneficiary which is the difference between the amount collected $50 and the limiting charge of 25. failure to comply may result in a fine up to $10,000 per violation or exclusion from participation in the federal healthcare programs for up to five years oh really that's a random place
According to social security act prohibitions on certain referral arrangements include those that are involved arrangements between entities and physician practices. In the law, rental of office space is considered not to be compensation arrangements under certain conditions and are considered exceptions as long as which of the following exists?
The rental charges over the term of the lease are consistent with fair market value, and are not determine any manner that takes into account the volume or value of any referrals or other business generated between the parties
Seven elements of program for individual and small group physician practices
The seven elements are conducting internal monitoring and auditing, implementing compliance and practice standards, designating a compliance officer or contact, conducting appropriate training and education, responding appropriately to detected offenses and developing corrective action, developing open lines of communication, and enforcing disciplinary standards through well-publicized guidelines
What is gainsharing?
The term gainsharing typically refers to an arrangement in which a hospital gives a physician a percentage share of any reduction in the hospital cost for patient care attributable in part of the physician efforts
What should physicians practice do if they are using another entities compliance materials?
They need to tailor the materials to be applied by the physician practice starting by the following, 1) develop written standards and procedures 2) updating clinical forms 3) make sure they facilitate encouraging clear and complete documentation of patient care
According to the OIG, medically unnecessary services should only be billed to Medicare and what circumstance?
To receive a denial so that the claim can be submitted to secondary payor
What are the additional requirements for teaching physicians?
Unless a service falls under a specified exception, the teaching physician must perform at the service or procedure for which payment is sought. 1)Physicians following respect to services provided the teaching physician. Every physician who provides services to patient is responsible for the correct services that were the tendered. Every physician is responsible for assuring in cases where the physiciarn provides evaluation and management (E&M) services, a patient's medical record includes appropriate documentation of the applicable key components of the E&M service provided or supervised by the physician patient history, physician examination, and medical decision making ) well documented to adequately reflect the procedure or portion of the services provided the physician, and Unless specifically excepted by document his or her presence during the key portion any service or procedure for which payment is sought.
The civil false claims act provide support with the authority to assess
Up to three times the amount of the damages which the government sustains
What do you validate reviewing policies and procedures?
Validate they are current and accurate if standards and procedures are found to be ineffective or outdated they should be updated to reflect changes in government regulations or compendiums generally relied upon by physicians and insurance for example CPT and ICD-10 codes
Select the best phrase from the list below to complete the following policy statement centennial medical associates is committed to the following federal, state, and local laws, rules, guidelines, and regulations. To promote this effort, Centennial medical associates will perform claim audits at least on an annual basis to?
Verify accuracy of coding and reimbursement for services performed
Penalties under civil monetary penalties law
Violation of the CMPL may result in a penalty up to $10,000 per item or service and up to three times the amount of on lawful claimed
A physician office laboratory is authorized to perform urinalysis testing, including the microscopic analyst under the provider performs microscopic procedures also known as PPMP certification. It has been the physicians experience that many of his patients have your analysis testing done also requires the microscopic exam. Because of all this and to be able to provide better treatment, he has established an office policy that for all your analysis testing performed in his office, the lab should also perform a microscopic Test. Is this a compliance risk?
Yes. Performing a microscopic test on all patients when the results of the urinalysis test are negative can be considered medically unnecessary.
What are the four basic risk areas developed by the OIG?
1) coding and billing 2) reasonable and necessary services 3) documentation 4) improper inducements
According to CLIA, personal performing waived tests must:
Be trained to perform the test, such as thorough on the job training
Example of false statement
Dr.X certified on a claim form that he preformed laser surgery on Medicare beneficiary when he knew that the surgery would not actually be performed on the patient. The penalty for this example include the imposition of the fine in person after five years or both
Penalties for false claims
False claims act is a minimum of $5500 up to a maximum of $11,000 for each false under claims submitted in addition to the penalty a provider could be found liable for damages up to three times amount of unlawful claimed
There can be a variety risks associated with joint ventures between hospitals and physicians. what law could be violated for improper joint ventures?
False claims act, Stark laws, anti-kickback statute
What are areas to monitor for that HCFA 1500 form?
Linking the diagnosis code to the visit service, use of modifiers appropriately, provide Medicare with all information about beneficiaries other insurance coverage under Medicare secondary payer policy, improper inducements kickbacks and self referrals
Under the HIPAA privacy rule, which of the following situations would require an authorization from the patient to release records?
Request from the life insurance company for the patient's medical records
A compliance program's open communication should include the following:
The requirement employees conduct themselves in good faith, and report anything to be fraudulent . The creation of user-friendly (such drop box for larger practices) for effectively reporting conduct; Provisions procedures that state that failure report erroneous or fraudulent conduct. compliance development of a simple and readily accessible procedure to process fraudulent conduct; billing company is used, communication to and from the billing company's compliance officer/contact and other responsible staff to coordinate billing and compliance activities.
Penalties under Stark law
Violations of the statute subject the billing entity to denial of payment for the doesn't need healthcare services refund of amounts collected for improperly submit claims and civil monetary penalty of the $15,000 for improper claim submitted, physician to Violate the statutes may be subject to additional fines per prohibited referral. In addition providers at inter-arrangements they should know or circumvents the referral. Physician maybe subjected of the Civil penalties up to $100,000 per arrangement
How does CMS define knowingly?
that a provider has actual knowledge that the information on the claim is false, ignorance of the truth or falsity delivery of information on the claim acts in reckless regard to the truth or falsity of the reckless information on the claim
