CPCO chapter 4
Exclusion can result from violating any section of the Civil Monetary Penalties Law, or from an individual or entity submitting a claim for reimbursement to a federal health care program for items or services furnished by an excluded person or entity. Penalties can be up to how much (prior to inflation)? $5,000 per claim, plus treble damages for the amount claimed for each item or service. $10,000 per claim, plus treble damages for the amount claimed for each item or service. $11,000 per claim, plus treble damages for the amount claimed for each item or service. $18,000 per claim, plus treble damages for the amount claimed for each item or service.
$11,000 per claim, plus treble damages for the amount claimed for each item or service. Exclusion from government programs is a key provision and penalty in the CMP law. Exclusion can result from violating any section of the CMP law, or from an individual or entity submitting a claim for reimbursement to a federal health care program for items or services furnished by an excluded person or entity. Penalties can be up to $11,000 per claim (prior to inflation), plus treble damages for the amount claimed for each item or service.
The Office for Civil Rights (OCR) has enforcement power for violations occurring as a result of willful neglect. The OCR can now impose civil monetary penalties of up to how much (prior to inflation) per HIPAA privacy regulations violation? $2,000 $10,000 $50,000 $75,000
$50,000 HIPAA privacy regulations restrict the use, access, and disclosure of protected health information (PHI) and other individually identifiable health care information. The Office of Civil Rights (OCR) has enforcement power for violations occurring as a result of willful neglect. The OCR can now impose civil monetary penalties of up to $50,000 per violation (prior to inflation).
The BBA of 1997 created an alternate sanction allowing the government to levy a civil fine of up to how much for each violation of the Anti-Kickback Statute? $20,000, and an assessment of three times the amount of the kickback $50,000, and an assessment of three times the amount of the kickback $75,000, and an assessment of three times the amount of the kickback $100,000, and an assessment of three times the amount of the kickback
$50,000, and an assessment of three times the amount of the kickback The government may levy a civil fine of up to $50,000 for each violation of the Anti-Kickback Statute, and an assessment of three times the amount of the kickback.
Penalties for mail fraud if the violation results in serious bodily injury is imprisoned up to how many years? 20 years 12 years 15 years 5 years
20 years Rationale: Penalties for mail fraud include fines and imprisonment of up to 20 years if the violation results in serious bodily injury (as defined in section 1365 of this title, 18 U.S. Code § 1347), such person shall be fined under this title or imprisoned not more than 20 years.
The ACA requires providers to refund an overpayment to Medicare within how many days of identifying it? 10 30 45 60
60 The Affordable Care Act now requires providers to refund an overpayment to Medicare within 60 days of "identifying" it, and provides that an overpayment retained beyond that deadline is an "obligation" under the FCA.
What are designated health services? Clinical Laboratory services Physical therapy services Home health services All of the above
All of the above Designated health services include:• Clinical laboratory services• Physical therapy services• Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services• Radiation therapy services including supplies• Parenteral and enteral nutrients, equipment, and supplies• Prosthetics, orthotics, and prosthetic devices and supplies• Home health services• Outpatient prescription drugs• Inpatient and outpatient hospital services
The Anti-Kickback Statute prohibits offering or payment of remuneration for which one of the following? A patient referral Money Gift All of the above
All of the above Under the Anti-Kickback Statute (AKS), it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal healthcare program. The statute prohibits both the offer or payment of remuneration for patient referrals, and the offer or payment of anything of value in return for purchasing, leasing, ordering, arranging for, or recommending the purchase, lease, or ordering of any item or service that is reimbursable by a federal healthcare program.
The OIG's publication of 5 Special Fraud Alerts addresses joint venture relationships. Which of the following is considered problematic by the OIG? Investors are chosen because they are in a position to make referrals. The joint venture includes a Shell Laboratory. Investors are required to divest their ownership interest if they cease to practice in the service area. All of the above
All of the above. To help you identify these suspect joint ventures, the following are examples of questionable features, which separately or taken together may result in a business arrangement that violates the Anti-Kickback Statute. Please note that this is not intended as an exhaustive list, but rather gives examples of indicators of potentially unlawful activity. Investors are chosen because they are in a position to make referrals. Physicians who are expected to make many referrals may be offered a greater investment opportunity in the joint venture than those anticipated to make fewer referrals. Physician investors may be actively encouraged to make referrals to the joint venture, and may be encouraged to divest their ownership interest if they fail to sustain an acceptable level of referrals.
If a group pays a hospital monthly rent for office space that is one-half the going rate or fair market value, this is a violation of which regulation? Stark Law FCA CMS guidelines Anti-Kickback Statute
Anti-Kickback Statute Examples of anti-kickback statute violations:• A hospital providing rental rates below fair market value to a physician who refers business to the hospital• Routine waiver of copayments or deductibles for patients under Medicare Part B• A drug or equipment supplier providing free benefits to a provider who utilizes their product• A physician who is paid exorbitantly for speaking engagements by a company to whom the provider refers business
XYZ Family Practice Group is renting space from the local hospital that owns rental property. A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital is in violation of which regulation? Anti-Kickback Statute Stark Law False Claims Act Qui Tam Provisions
Anti-Kickback Statute Examples of the Anti-Kickback Statute violations:• A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital.• Routine waiver of co-payments or deductibles for patients under Medicare Part B.• A drug or equipment supplier providing free benefits for a provider who utilizes their product.• A physician who is paid large amounts for speaking engagements by a company whom the provider refers business to.
What regulations may some joint ventures may violate? Anti-Kickback Statute False Claims Act Claims processing manual Enrollment process
Anti-Kickback Statute The Office of Inspector General believes that some joint ventures may violate the Medicare and Medicaid Anti-Kickback Statute.
Under what circumstances can a relator not file or pursue a qui tam action? If they are a new employee The qui tam action is based upon information that has been disclosed to the public The government already is a party to a civil or administrative money proceeding Both b and c
Both b and c The FCA provides several circumstances when a relator cannot file or pursue a qui tam action:1 - The relator was convicted of criminal conduct arising from his or her role in the FCA violation2 - Another qui tam concerning the same conduct already has been filed (this is known as the "first to file bar")3 - The government already is a party to a civil or administrative money proceeding concerning the same conduct4 - The qui tam action is based upon information that has been disclosed to the public through any of several means: criminal, civil, or administrative hearings in which the government is a party, government hearings, audits, reports, or investigations, or through the news media (this is known as the "public disclosure bar"). There is an exception to the public disclosure bar where the relator was the original source of the information.
Deficit Reduction Act (DRA) requires that providers who have more than $5 million either received or paid to the reimbursement from state Medicaid programs inform employees of their ability to__________? Bring a whistleblower action File paper claims E-prescribe medications to reduce errors Self-disclose overpayments within 90 days
Bring a whistleblower action DRA also requires that providers who have more than $5 million dollars either received or paid to the reimbursement from state Medicaid programs to provide training and educate employees on the FCA and inform employees of their ability to bring a whistleblower action.
The Compliance Officer at XYZ Family Practice Office explains to the Board that submitting claims provided by excluded individuals or entities to government programs such as Medicare or Medicaid faces a penalty related to: Civil Monetary Penalty False Claims Act Stark Law Anti-Kickback Statute
Civil Monetary Penalty Providers such as hospitals, nursing homes, hospices, and group medical practices may face CMP penalties if they submit claims to a federal healthcare program for healthcare items or services provided directly or indirectly by excluded individuals or entities.
The Compliance Officer at Apple Internal Medicine Group explains to the Board that there is a difference between the False Claims Act (FCA) Civil and Criminal law. What is the difference between them? Coding mistakes are fined under Civil but not Criminal. Criminal states that proof must be beyond a reasonable doubt. Civil involves fines as a penalty. Criminal involves jail time only. Civil and Civil Monetary Penalties work together. Criminal FCA does not work with Civil Monetary Penalties.
Criminal states that proof must be beyond a reasonable doubt. The FCA does not encompass mistakes, errors, or negligence. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.
Tim is the Compliance Officer for the Apple Internal Medicine Group. He conducts the in-service training for all new employees. He discusses the 5 most important federal fraud and abuse laws. These are: FCA, AKS, Stark, Exclusion, CMPL ACA, OIG, CMS, ACO, FCA FCA, AKS, Stark, CMPL, OIG Stark, AKS, Exclusion, FCA, OIG
FCA, AKS, Stark, Exclusion, CMPL The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws.
A basic concept in the Anti-Kickback safe harbors and Stark exceptions is that financial transactions between potential referring parties be conducted under what condition? Fair market value A referral on file In a hospital setting In an outpatient facility
Fair market value The Anti-Kickback statute also contains safe harbors (42 CFR 1001.952 (a)-(u)). Arrangements not fitting into a safe harbor do not automatically violate the anti-kickback law. A basic concept in the Anti-Kickback safe harbors and Stark exceptions is that financial transactions between potential referring parties be conducted at fair market value.
Fraud and Abuse Recovery Act (FERA) expands the grounds for liability under which Act? False Claims Act Medicare Modernization Act Racketeer Influenced and Corrupt Organization Act Mail Fraud
False Claims Act Fraud and Abuse Recovery Act (FERA) expands the grounds for liability under the False Claims Act.
Which Act of 2003 gave momentum to the e-prescribing movement, and was put in place to reduce medication errors due to illegible physician handwriting, etc.? Medicare Modernization Act (MMA) Deficit Reduction Act (DEFRA) False Claims Act (FCA) Fraud Enforcement and Recovery Act (FERA)
Medicare Modernization Act (MMA) The Medicare Modernization Act (MMA) of 2003 was put in place to reduce medication errors due to illegible physician handwriting, etc., and gave momentum to the e-prescribing movement.
A Board member of the Apple Internal Medicine Group wants to call the OIG hot line to "self-disclose." Is he allowed to do this? Yes, The OIG allows all methods of self-disclosure. No, The OIG does not allow self-disclosure via hot line. Yes, The OIG prefers the hot line for self-disclosures. No, The OIG only allows faxed self-disclosure forms.
No, The OIG does not allow self-disclosure via hot line. A self-disclosure cannot be completed via the OIG Hotline. There are certain protocols that need to be followed. Disclosures must be made in good faith. The OIG will not continue to work with a provider that attempts to circumvent an ongoing inquiry or fails to fully cooperate it he self-disclosure process.
Larry is the coder and biller at Orange Medical Group. He is afraid that if he makes a simple mistake, he will be fined under the False Claims Act. Is Larry's concern valid? Yes. Larry needs to know the law and follow them because he could be fined when he makes any mistakes. No. Larry needs to know the laws, but if a mistake is made and then corrected, he will not be fined under the False Claims Act. Yes. Larry would be held accountable under the False Claims Act. No. Larry is only accountable under the Stark Law.
No. Larry needs to know the laws, but if a mistake is made and then corrected, he will not be fined under the False Claims Act. The Civil Monetary Penalty Law and the False Claims Act (FCA)—are related to proper claims filing. Mere mistakes, which can be remedied by returning overpayments, do not result in violations of these laws.
The RICO Act is a law that increases the severity of penalties for violations of what? HIPAA Human resources Organized crime Improper claim submissions
Organized crime The RICO Act is a law that increases the severity of penalties for violations involving organized crime.
Tim is the Compliance Officer at Apple Internal Medicine Group. He explains to the Apple Internal Group Board that the False Claims Act covers claims that are billed to Medicare. This can include which of the following: Part A and B only. Part D only for prescriptions. Part A for hospitals only. Part A, B, C and D.
Part A, B, C and D. Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. Civil monetary penalty (CMP) law and the False Claims Act (FCA) are related to proper claims billing. These bodies of law specify the criminal and/or civil remedies the government can impose upon individuals or entities that commit fraud and abuse in the Medicare program, including Medicare Parts C and D, and the Medicaid program.
Which safe harbor can shelter physician independent contractor-type agreements with hospitals or other providers, such as skilled nursing facilities (SNFs)? Personal services Referral service Reduced cost sharing Space rental
Personal services The personal services safe harbor can shelter physician independent contractor-type agreements with hospitals or other providers, such as skilled nursing facilities (SNFs). These agreements include medical directorships, on-call agreements, hospital-based services, etc. The safe harbor requires a written agreement, with a term of a least one year. Compensation must be set in advance (e.g., per month or an hourly rate).
Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for employing excluded entities or providers. How often should he check the OIG List of Excluded Individuals Entities on the OIG website? Monthly only Prior to hiring only Prior to hiring and monthly thereafter Prior to hiring and annually thereafter
Prior to hiring and monthly thereafter To avoid liability for employing excluded entities, providers should check the OIG List of Excluded Individuals Entities on the OIG website, as well as any state exclusion website. Providers can purchase services that can check exclusion status in real time. Prior to hiring a permanent or contract employee, the provider should check the exclusion list, and do so monthly thereafter, so that there is little chance of submitting claims for an excluded person.
The Civil Monetary Penalty Law and the False Claims Act are related to which one of the following? Mail Fraud Improper inducements Proper claims filing Racketeer Influenced and Corrupt Organization Act
Proper claims filing Two laws—The Civil Monetary Penalty Law and the False Claims Act are related to proper claims filing. Mere mistakes, which can be remedied by returning overpayments, does not result in violations of these laws.
Civil actions may be brought in federal district court under the False Claims Act by the Attorney General, or by a person known as a relator, in what type of action? Disciplinary Evidence Based Qui Tam Antitrust
Qui Tam Civil actions may be brought in federal district court under the False Claims Act by the Attorney General, or by a person known as a relator (e.g., a "whistleblower"), in what is termed a qui tam action.
Dr. X at XYZ Family Practice Group wants to know if he can accept gifts. Providers can give physicians gifts and other benefits up to a set amount each year, adjusted for inflation. Gifts and benefits should be tracked: If the set amount is exceeded, what can the physician do? Donate the excess to charity. Repay the excess. Off set the balance for the next year. Keep the money because no one is enforcing the rule.
Repay the excess. Sometimes, other payments between providers and physicians are exempt from the Stark law. Generally, there is a broad exception in the regulation for fair market value compensation that is in writing for a set time frame, with set compensation. Providers can give physicians gifts and other benefits up to a set amount each year, adjusted for inflation. Gifts and benefits should be tracked: If the set amount is exceeded, the physician can repay the excess.
Which law provides for a civil monetary penalty (up to $15,000 per service) and exclusion from government programs in any case where a person submits an improper claim, which was known to have been, or should have been known to have been, provided through a prohibited referral, and has not refunded the payment? Anti-Kickback Statute Health Insurance Portability and Accountability Act Qui Tam Provisions Stark Law
Stark Law The Stark law prohibits payments for certain "Designated Health Services" provided through a prohibited referral and requires refunds for any amounts improperly billed and collected. It provides for a civil monetary penalty (up to $15,000 per service) and exclusion from government programs in any case where a person submits an improper claim, which was known to have been, or should have been known to have been, provided through a prohibited referral, and has not refunded the payment.
Routine waiver of co-pays would be considered a violation of which law? The Anti-Kickback Statute Stark Law False Claims Act HIPAA
The Anti-Kickback Statute Examples of anti-kickback statute violations include:• A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital• Routine waiver of copayments or deductibles for patients under Medicare Part B• A drug or equipment supplier providing free benefits for a provider who utilizes their product• A physician who is paid exorbitantly for speaking engagements by a company to whom the provider refers business
With regard to public disclosure, whistleblowers cannot bring claims based on information that has been disclosed in the following circumstances EXCEPT: In a criminal, civil, or administrative hearing. In a congressional, administrative, or Government Accountability Office (GAO) report, hearing, audit, or investigation. News media. With personal knowledge of the claim.
With personal knowledge of the claim. Qui tam action is a powerful weapon against healthcare fraud because a private party with independent knowledge of wrongdoing may initiate the action.
Hannah is afraid that if she reports the allegation of fraud that she thinks is occurring at her medical office that she will be fired. Could this occur? Yes. The employer has the right to terminate her under any circumstances. No. The employer can only demote or suspend her. Yes, but the employer would be in violation of the Whistleblower Protection Law. No. There needs to be grounds for all job terminations.
Yes, but the employer would be in violation of the Whistleblower Protection Law. The False Claims Act provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action.
ABC Medical Practice hires a consultant to review the accounts receivable. The consultant assesses the receivables and notices a large amount of denials for medical necessity. Upon interviewing the billing staff, the consultant discovers that when the billing staff receives a denial for medical necessity, the medical policy for that insurance carrier is reviewed. Based on the policy reviewed, the diagnosis for the denied service is changed to a payable diagnosis, without reviewing the documentation, and is rebilled. The consultant advises the billing manager that this is happening and provides the steps to check the claims against documentation, and refund the money. The billing manager reviews the documentation and refunds the money but does not change the practice of how the medical necessity denials are handled. Can ABC Medical Practice be held liable under the False Claims Act? No; because the claims billed incorrectly were reviewed and money returned, the practice is not liable. No, billing for services without supporting documentation for the diagnosis does not constitute a false claim. Yes; the billing manager knowingly allowed claims to be refiled without supporting documentation. Treble damages, plus a penalty of $10,500 to $21,000 for each false claim filed.
Yes; the billing manager knowingly allowed claims to be refiled without supporting documentation. According to the DOJ's primer on the False Claims Act, a person does not violate the law by submitting a false claim to the government. To violate the False Claims Act, a person must have submitted, or caused the submission of, the false claim (or made a false statement or record) with knowledge of the falsity. Knowledge of false information is defined as being:1-Actual knowledge;2-Deliberate ignorance of the truth or falsity of the information;or3-Reckless disregard of the truth or falsity of the information.The False Claims Act defines a claim as a demand for money or property made directly to the federal government or to a contractor, grantee, or other recipient if the money is to be spent on the government's behalf and if the federal government provides any of the money demanded or if the federal government will reimburse the contractor or grantee. Because the billing manager was aware of the practice changing the diagnosis based on a medical policy, without review of the documentation, the practice is aware that false claims are being sent.
Which of the following represents a violation of the Stark Law? the referring physician, or an immediate member of the referring physician's family, has a financial relationship with the entity receiving the referral. the referring physician's best friend from medical school owns the entity receiving the referral. the referring physician's neighbor owns the entity receiving the referral. the referring physician's chiropractor owns the entity receiving the referral.
the referring physician, or an immediate member of the referring physician's family, has a financial relationship with the entity receiving the referral. Stark Law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. Specifically, if a physician (or immediate family member) has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services (DHS) for which the Medicare or Medicaid program would otherwise pay.
Stark law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. An example of this is if a physician or his ____________ has a financial relationship with an entity. wife cousin friend All of the above
wife Immediate family member. The Stark law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. Specifically, if a physician (or immediate family member) has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services (DHS) for which the Medicare or Medicaid programs would otherwise pay.