Chapter 4
a. 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.
A Relator is the: a. The Whistleblower b. The Provider who makes the complaint. c. Hospital where the complaint is made. d. The OIG agent that intervenes.
c. 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.
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? a. A referral on file b. In an outpatient facility c. fair market value d. In a hospital setting
b. 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.
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? a. HIPAA b. Anti-kickback and Stark laws c. Civil Monetary Penalty Law and the False Claims Act (FCA)— d. OSHA
a. 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).
Circumnavigation schemes can occur when a physician or other entity enters into an arrangement that the entity /physician knows that ____________will occur. a. referrals b. payments c. gifts d. patient transfers
c. 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 ($392 in 2016)). Gifts and benefits should be tracked: If the set amount is exceeded, the physician can repay the excess.
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 ($392 in 2016). Gifts and benefits should be tracked: If the set amount is exceeded, the physician can ___________? a. Off set the balance for the next year b. Keep the money because no one is enforcing the rule. c. Repay the excess. d. Donate the excess to charity
a. $2,000 Response Feedback: Hospitals are prohibited from making payments, directly or indirectly, to a physician as an inducement to reduce or limit services provided to Medicare or Medicaid patients. The hospital is subject to a civil money penalty of not more than $2,000 for each individual for whom the payment is made.
Hospitals are prohibited from making payments, directly or indirectly, to a physician as an inducement to reduce or limit services provided to Medicare or Medicaid patients. The hospital is subject to a civil money penalty of not more than how much for each individual for whom a payment is made? a. $2,000 b. $3,000 c. $5,000 d. $4,000
b. 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.
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? a. Terminate them immediately and refund the government payer. c. Do not allow the employee to provide services to government program patients d. Do not allow the employee to provide services and remove their salary from the Medicare cost report.
d. 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
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? a. Stark Law b. CMP c. Qui Tam d. Anti-kickback
d. Up to $ 21,563, 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 $21,563 per claim, plus the assessment of not more than three times the amount claims for damages.
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? a. Up to $25,000, plus the assessment of not more than three times the amount claimed for damages b. Up to $20,000, plus the assessment of not more than three times the amount claimed for damages c. Up to $10,781, plus the assessment of not more than three times the amount claimed for damages d. Up to $ 21,563, plus the assessment of not more than three times the amount claimed for damages
a. 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. Response Feedback: 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.
Larry is the coder / 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 concerns valid? a. 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. b. Yes, Larry needs to know the law and follow them because he could be fined if he makes any mistakes. c. Yes. Larry would be held accountable under the False Claims Act. d. No. Larry is only accountable under the Stark Laws.
a. Stark Response Feedback: Because these businesses provide designated health services, Stark is triggered.
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? a. Stark b. FCA c. Qui Tam d. Anti-kickback
c. 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 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: a. FCA and OSHA b. OSHA and HIPAA c. Patient Safety and Information Security d. Compliance and ADA Laws
b. 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.
The Civil Monetary Penalty Law and the False Claims Act are related to_______? a. RICO b. Proper claims filing c. Mail Fraud d. Improper inducements
b. Civil and CMP work together. Criminal FCA does not work with CMP. Response Feedback: The FCA does not encompass mistakes, errors, or negligence. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.
The 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: a. Civil involves fines as a penalty. Criminal involves jail time only. b. Civil and CMP work together. Criminal FCA does not work with CMP. c. Criminal states that proof must be beyond a reasonable doubt. d. Coding mistakes are fined under Civil but not Criminal.
c. 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.
The Medicare Modernization Act (MMA) of 2003 gave momentum to what movement? a. Electronic health record movement b. Quality movement c. e-prescribing movement d. Whistleblower movement
d. $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.
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. a. $10,000 b. $2,000 c. $75,000 d. $50,000
d. 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 Office of Inspector General (OIG) works from within what organization to identify vulnerabilities in the health care system? a. OCR b. CMS c. Medicaid d. HHS
a. FCA, AKS, Stark, Exclusion, CMPL Response Feedback: 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.
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: a. FCA, AKS, Stark, Exclusion, CMPL b. ACA, OIG, CMS, ACO, FCA c. FCA, AKS, Stark, CMPL, OIG d. Stark, AKS, Exclusion, FCA, OIG
b. Prior to hiring and monthly thereafter Response Feedback: 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.
Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for employing excluded entities or providers. He should check the OIG List of Excluded Individuals Entities on the OIG website how often? a. Prior to hiring only b. Prior to hiring and monthly thereafter c. Prior to hiring and annually thereafter d. Monthly only
c. 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.
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? a. Anti-Kickback b. Qui Tam c. Stark d. HIPAA
d. 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.
Which type of fraud covers any criminal fraudulent activity that has been determined to have involved electronic communications of any kind? a. DEFRA b. RICO c. Mail fraud d. Federal wire fraud (18 USC1343)
d. Any private party with independent knowledge of wrongdoing Response Feedback: Qui tam actions are a powerful weapon against health care fraud because a private party with independent knowledge of wrongdoing may initiate the action.
Who can initiate a Qui Tam action? a. Employees only b. Administrators only c. Patients only d. Any private party with independent knowledge of wrongdoing
d. 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
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 what statute? a. Stark Law b. Qui Tam c. FCA d. Anti- Kickback
c. 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.
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? a. Disciplinary b. Evidence Based c. Qui Tam d. Antitrust
c. False Claims Act Response Feedback: FERA expands the grounds for liability under the FCA.
FERA expands the grounds for liability under which Act. a. Medicare Modernization Act b. Mail Fraud c. False Claims Act d. RICO