CPCO Chapter 4 Review Key Enforcement Laws

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 how much per HIPAA privacy regulations violation.

$50,000 Response Feedback: 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.

Penalties for mail fraud if the violation results in serious bodily injury is imprisoned up to how many years?

20 years Response Feedback: 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 Health Reform Act requires providers to refund an overpayment to Medicare within how many days of "identifying" it

60 Response Feedback: The Health Reform 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 (discussed in more detail, below).

Judy is the front office assistant at XYZ Family Practice Group. She wants to know why she can't waive co-pays on a regular basis if the patient can't pay. Routine waiver of co-payments or deductibles for patients under Medicare Part B is in violation of what Statute?

Anti-kickback Response Feedback: 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

A board member of XYZ Family Practice Group asks the Compliance Officer "What two laws relate primarily to the relationships between referral sources, such as physicians and hospitals?" What is the answer?

Anti-kickback and Stark laws Response Feedback: Two additional laws—the Anti-Kickback and Stark laws—relate primarily to the relationships between referral sources, such as physicians and hospitals.

The Compliance Officer at Apple Internal Medicine Group explains to the Board that there is a difference between the FCA Civil and Criminal law. The difference is:

Criminal states that proof must be beyond a reasonable doubt. Response Feedback: Answer is b. 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.

Which Act provides a financial incentive for states to enact false claims acts that establish liability to the state for the submission of false or fraudulent claims to the state's Medicaid program?

Deficit Reduction Act of 2005 (DEFRA) Response Feedback: DEFRA provides a financial incentive for states to enact false claims acts that establish liability to the state for the submission of false or fraudulent claims to the state's Medicaid program. If a state FCA is determined to meet certain requirements, the state is entitled to receive a greater monetary recovery with respect to any amounts recovered under a state action brought under such a law.

The Medicare Modernization Act (MMA) of 2003 gave momentum to what movement?

E-prescribing movement Response Feedback: The Medicare Modernization Act (MMA) of 2003 gave momentum to the e-prescribing movement, and was put in place to reduce medication errors due to illegible physician handwriting, etc. Adopting the standards to facilitate e-prescribing is one of the key action items in the government's plan to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States.

FERA expands the grounds for liability under which Act.

False Claims Act Response Feedback: FERA expands the grounds for liability under the FCA.

Which type of fraud covers any criminal fraudulent activity that has been determined to have involved electronic communications of any kind?

Federal wire fraud (18 USC1343) Response Feedback: Federal wire fraud (18 USC1343) covers any criminal fraudulent activity that has been determined to have involved electronic communications of any kind.

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

HHS Response Feedback: The Office of Inspector General (OIG) works from within HHS to identify vulnerabilities in the health care system to offer compliance guidance to health care facilities and professionals, and to promote accountability and enforce regulation.

The Apple Internal Medicine Group is having a board meeting. Tim, the Compliance Officer explains that ________ is the most important concern for the Apple Internal Medicine Group Human Resource Department.

Patient Safety and Information Security Response Feedback: Patient safety and information security is one of the leading concerns for healthcare human resources and corporate security personnel. It is paramount to develop the right partnerships to mitigate risk, maintain regulatory compliance, and improve patient safety.

The Civil Monetary Penalty Law and the False Claims Act are related to?

Proper claims filing Response Feedback: 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 FCA by the Attorney General, or by a person known as a relator, in what type of action?

Qui Tam Response Feedback: Civil actions may be brought in federal district court under the FCA by the Attorney General, or by a person known as a relator (e.g., a "whistleblower"), in what is termed a qui tam action.

Which law increases the severity of penalties for violations involving organized crime?

RICO Act Response Feedback: The RICO (Racketeer Influenced and Corrupt Organizations) Act is a law that increases the severity of penalties for violations involving organized crime.

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 ($398 in 2017). Gifts and benefits should be tracked: If the set amount is exceeded, the physician can ___________?

Repay the excess Response Feedback: 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 ($398 in 2017). Gifts and benefits should be tracked: If the set amount is exceeded, the physician can repay the excess.

If physician recruitment arrangements are not properly structured it can result in

Significant fines and penalties. Response Feedback: Physician recruitment arrangements receive tremendous scrutiny. These arrangements are subject to complex rules and regulations, and if not properly structured can result in significant fines and penalties.

Joan is one of the coders/billers at XYZ Family Practice Office. She tells her husband that she thinks XYZ is committing fraud. He advises her to discuss this with her supervisor. After she leaves for work, he calls an attorney to tell him about the issue and to file a Qui Tam. It is likely the attorney will say:

Sorry, but you do not have firsthand / actual knowledge of the facts. Response Feedback: Civil actions may be brought in federal district court under the FCA by the attorney general, or by a relator (whistleblower), in a 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. FCA recoveries fund government programs and are a big part of paying for health reform.

Physicians sometimes own other health-related businesses, such as physical therapy facilities, DME or home health companies, diagnostic imaging centers, or laboratories. Because these businesses provide designated health services, what may be triggered?

Stark Response Feedback: Physicians sometimes own other health-related businesses, such as physical therapy facilities, DME or home health companies, diagnostic imaging centers, or laboratories. Because these businesses provide designated health services, Stark is triggered.

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?

Stark Response Feedback: 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.

Joan is an employee at XYZ Family Practice. She asks the Compliance Office what should you do when you find out one of your employees has been excluded from government programs?

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

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

The Balanced Budget Act (BBA) Response Feedback: The Balanced Budget Act (BBA) authorized the imposition of Civil Monetary Penalties against health care providers and entities that employ or enter into contracts with excluded individuals or entities to provide items or services to federal program beneficiaries.

John is a student reviewing the information regarding compliance and wants to know "who" or what agency is responsible for oversight of the Medicare and Medicaid Programs?

The U.S. Department of Health & Human Services (HHS) Response Feedback: The U.S. Department of Health & Human Services (HHS) oversees Medicare, Medicaid, public health, medical research, food and drug safety, welfare, child and family services, disease prevention, Indian health, and mental health services; and, it exercises leadership in public health emergency preparedness and combating bioterrorism.

A Relator is the:

The Whistleblower Response Feedback: Civil actions may be brought in federal district court under the FCA by the attorney general, or by a relator (whistleblower), in a qui tam action.

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

There is no current criminal or civil enforcement action pending Response Feedback: If there is no current criminal or civil enforcement action pending, a person or entity may voluntarily disclose a violation and if they cooperate with any ensuing investigation and satisfy certain other criteria, the damages will be doubled instead of tripled.

Civil liability under the FCA can result in how much in fines?

Treble damages, plus a penalty of $10,957 to $21,916 for each false claim filed. Response Feedback: The FCA imposes civil liability on persons who knowingly submit a false or fraudulent claim, or engage in various types of misconduct involving federal government money or property. Health care program false claims include billing for services not rendered, billing for unnecessary medical services, double billing for the same service or equipment, or billing for services at a higher rate than provided (upcoding). Penalties under the FCA include treble damages, plus a penalty of $10,957 to $21,916 for each false claim filed.

Kim is a new coder at XYZ Family Practice and she asks the Compliance Officer what is the maximum federal penalty amounts per false claim violation. What is the Compliance Officers response?

Up to $21,916, plus the assessment of not more than three times the amount claimed for damages Response Feedback: Congress has increased the strength of the civil monetary penalty law over the years. The penalties for false claims is up to $21,916 per claim, plus the assessment of not more than three times the amount claims for damages.

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 Response Feedback: 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

With regard to public disclosure, whistleblowers cannot bring claims based on information that has been disclosed in the following circumstances EXCEPT:

With personal knowledge of the claim. Response Feedback: Qui tam action is a powerful weapon against healthcare fraud because a private party with independent knowledge of wrongdoing may initiate the action.

Texas orthopedics submits false Medicare claims through its electronic data interchange to its Medicare Administrative contractor based in Oklahoma. Can the orthopedic office be charged with federal wire fraud?

Yes, because false claims were submitted electronically across state lines. Response Feedback: Federal wire fraud (18 USC 1343) covers any criminal fraudu¬lent activity that is determined to involve electronic communications of any kind. The citation specifically states: "Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, trans¬mits or causes to be transmitted by means of wire, radio, or television communication in interstate or foreign commerce, any writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or artifice, shall be fined under this title or imprisoned not more than 20 years, or both." This type of fraud involves such activities as transmitting claims for reimbursement through the Internet or Facsimile. It can also include telephone solicitation when fraud is the objective such as in the case of Medicare Parts C and D programs, supplemental insurance plans, private insurance programs, and DME solicitation. Fraudulent claims submitted electronically across state lines or internationally have the potential to be in violation of this statute.

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, but the employer would be in violation of the Whistleblower Protection Law. Response Feedback: The FCA 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.

Under the anti-kickback statute, it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal healthcare program. This would include all of the following:

a. a referral b. Money c. Gift Correct answer d. All of the above Response Feedback: 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.

Some joint ventures may violate the Medicare and Medicaid ______________?

anti-kickback statute Response Feedback: The Office of Inspector General believes that some joint ventures may violate the Medicare and Medicaid anti-kickback statute.

If the government intervenes in the qui tam action, the relator is entitled to receive how much of the amount recovered by the government through the qui tam action?

between 15 and 25 percent Response Feedback: If the government intervenes in the qui tam action, the relator is entitled to receive between 15 and 25 percent of the amount recovered by the government through the qui tam action. If the government declines to intervene in the action, the relator's share is increased to 25 to 30 percent.

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 Response Feedback: 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.

Circumnavigation schemes can occur when a physician or other entity enters into an arrangement that the entity /physician knows that ____________will occur.

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