Chapter 10
Red Flags Rule
- requires businesses and organizations to implement a written identity theft prevention program -enforced by the False Claims Act
Emergency Medical Treatment and Labor Act (EMTALA)
known as the patient antidumping statute -ensures public access to emergency services regardless of the ability to pay
Anti-Kickback Statute
makes knowingly offering, paying, soliciting, or receiving any remuneration to reward referrals to services reimbursable by a federal program a criminal offense.
conditions of participation
CMS developed health and safety standards for improving quality of care and protecting the health and safety of patients that must be met in order for a healthcare organization to participate in Medicare and Medicaid programs. The Standards are called
returned overpayments
EXAMPLES OF HIGH-RISK BILLING PRACTICES WHICH CREATE COMPLIANCE RISKS FOR HEALTHCARE ORGANIZATIONS INCLUDE ALL BUT WHICH OF THE FOLLOWING?
compliance plan
Establishing a process to receive complaints and a procedure to protect the anonymity of complainants is one of the required elements in a
Potentially Compensable Events (PCE)
an event that may result in financial liability for healthcare organization
true
If the qui tam lawsuit is not successful and the defendant wins, the whistleblower could be required to pay the defendant's attorney fees if the government did not join the case
fraud
Knowingly and willingly executing pr attempting to execute a scheme to obtain by means of false or fraudulent pretense, representations, or promises money or property owned by any healthcare benefit program is
HIPAA
Legislation which increases attention on investigating, preventing and prosecuting fraud and abuse in Medicare
incident reporting
Notification to risk manager of an unplanned or unusual occurrence, such as patient falls, medication errors, and employee injuries
•Natural threats (floods) •Technical/man-made (mechanical, biological) •Intentional acts (computer security)
There are three major categories of threats
true
The Red Flags rule required financial institutions and creditors to establish identity theft protection programs. These would likely only apply to healthcare organizations that use credit reports or furnish information to consumer reporting agencies as a regular part of business.
civil monetary penalties law
The legislation provides punitive fines imposed by a civil court to organizations that profit from illegal or unethical activities.
false claims act
This act is used to combat medicare fraud by penalizing those that submit incorrect information to the program
fraud
an intentional deception or misrepresentation
stark law
This law prohibits a physician from referring certain health services to an entity in which the physician (or member of immediate family) has an ownership or investment or with which physician has a compensation arrangement, unless an exception applies
Office of Inspector General
This organization provides new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services.
yes, protection is provided whether the allegations are found to be true or untrue
Under the False Claims Act, is protection provided to the individual who discloses the corruption to the authorities, also known as whistle-blower
fraud
a pharmacist who submits medicaid claims for reimbursement of brand name drugs when less expensive generic drugs were actually dispensed has committed the crime of
Emergency Medical Treatment Active Labor Act
Which Act was passed to stop the practice of refusing to treat people because of inability to pay or insufficient insurance?
provide annual reports of non-compliance
Which of the following is not one of the seven elements of a compliance program per CMS and the OIG's recommendations -provide annual reports of non compliance -estalbish a formalized compliance committee -measure effectiveness through ongoing audits -designate compliance officer
abuse
any practice that creates unnecessary cost to federal healthcare programs -practices that are inconsistent with sound fiscal, business, or medical practices
risk management
___ programs should include both identification of potentially compensable events and routine monitoring
enterprise risk management
______ is an ongoing risk management process that flows through an entity versus being applicable to only certain units or people of the entity
recovery audit contractors
as the coding supervisior, your job description includes working with agents who have been charges with detecting and correcting overpayments made to your hospital in the Medicare- Fee-for Service program. You will need to develop a professional relationship with
provider's documentation
coding and billing documentation must be based on the
office of the inspector general
coding compliance programs focus on preventing accusations of fraud and abuse in healthcare. Which organization from the Department of Health and Human Services provides guidance for Healthcare organizations in developing compliance programs
OIG audits
evaluates its annual work plan and is dedicated to combating fraud, waste and abuse by providing oversite and resources to improve the efficiency of the HHS programs
safe harbors
exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution
laws
federally enforceable
qui tam
healthcare fraud and abuse laws provide a whistleblower provision also known as
risk management plan
identification of threats and vulnerabilities, security measures, and implementation priorities are part of a health care organization's
fraud
if an HIM department acts in deliberate ignorance or in disregard to official coding guideline, it may be comitting
kickbacks
if an HIM department receives gifts from vendors in exchange for purchasing a specific encoder software, this is
regulations
implementation details of the law and are also legally enforceable
risk control
includes avoidance, prevention, reduction, segregation, and non-insurance transfer
MACs (Medicare Administrative Contractors)
perform pre-payment reviews to ensure services provided Medicare beneficiaries are covered and medically necessary
patients who are in active labor
the EMTALA law ensures medical care is delivered to which of the following patient groups
identity theft
the Fair and Accurate Credit Transactions Act Works to reduce...
made compliance programs mandatory
the deficit reduction act of 2006...
stark law
the federal physician self-referral statute is also known as the
the government's investigative powers
the fraud enforcement and recovery act expands...
both criminal and civil penalties
the intent of the seven fundamental elements to a compliance program are designed to deter non-compliance. What is the potential penalty from the federal government for healthcare non-compliance
Failure to use a comprehensive code to inappropriately maximize reimbursement
unbundling refers to
if they submit a false claim to the federal government
under the false claims act, any person can be held liable if they knowingly submit a fraudulent claim to whom
exclusion and civil penalties
violations of EMTALA can result in
red flags rule
what is the name of the rule enacted by the false claims act which requires businesses and organizations to implement a written identity theft prevention program
intentional deception
which of the following accurately describes criminal healthcare fraud
MIA
which of the following groups are not federal programs used to control and monitor for healthcare fraud, waste, and abuse -RAC -HEAT -MAC -MIA
-conduct audit trails to monitor inappropriate access to system information
which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but not on the job description of chief privacy officer? -monitor the facility's business associate agreements -oversee the patient's right to inspect, amend, and restrict access to protected health information -conduct audit trails to monitor inappropriate access to system information -cooperate with the OCR in compliance investigations
a physician referring a patient to a dialysis center in which he is part owner
which of the following scenarios would violate stark law
RACs (Recovery Audit Contractors)
work with a mission of reducing Medicare improper payments through detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments
US Sentencing Commission Guidelines
•Defines individual and organizational criminal conduct •Defines sentencing and fines guidelines for individual and organizational criminal conduct •Provides compliance guidelines for reducing or preventing criminal conduct
corporate integrity agreements (CIA)
•are imposed when serious misconduct (fraud and abuse) is discovered through audits or self-disclosure and can last for several years. -•The OIG negotiates _____ with healthcare providers and entities so they are not excluded from participation in federal healthcare programs.
compliance officers
•are ultimately responsible for making sure employees adhere to a code of conduct and to provide timely reporting of compliance violations. -is responsible for identifying and locating primary law sources
HEAT (Health Care Fraud Prevention and Enforcement Action Team)
•identify fraud perpetrators and those preying on Medicare and Medicaid beneficiaries
corporate compliance program
•is designed to help detect and prevent the violations of fraud, waste, and abuse.
contingency planning
•is part of an emergency preparedness process and includes business practices, operational continuity, and disaster recovery planning. -includes plans to be followed in order to continue normal business operations
MICs (Medicaid Integrity Contractors)
•review Medicaid claims to determine potential provider waste or abuse, identify overpayments, and provide education to providers on payment integrity and quality of care issues
waste
•technically not a legal term; however, CMS identifies waste as encompassing over-utilization, under-utilization, and misuse of resources. •It is not typically intentional or criminal in nature but does have a financial impact on services.
