FOL Chapter 18 Study

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital?

$39,375

Safe Harbor for Electronic Health Records Items and Services

(AKS safe harbor, also an exception under the Stark Law) intended to protect beneficial arrangements that would eliminate perceived barriers to the adoption of EHRs without creating undue risk that the arrangements might be used to induce or reward the generation of federal healthcare program business; protects certain arrangements involving the provision of interoperable EHR software or information technology and training services

This act is used to combat Medicare fraud by penalizing those that submit incorrect information to the program. - False Claims Act - Medicare Act - Fraud Prevention Act - Qui Tam Act

False Claims Act

For a provider to be liable under the False Claims Act, there must be proof of a specific intent to defraud. (T/F)

False; "no proof of specific intent to defraud is required"

The Deficit Reduction Act extended the application and scope of the current civil monetary penalty and exclusion authorities beyond programs funded by HHS to all federal healthcare programs. (T/F)

False; HIPAA did this, the DRA began the process of transforming compliance programs from voluntary to mandatory

The Government Accountability Office recommended that increased use of prepayment edits would help prevent improper Medicare payments. (T/F)

False; I don't know, I didn't see anything uhhh, they say use of predictive analytics lol

The Stark Law is another name for the Anti-Kickback Statute. (T/F)

False; Stark Law is another name for the Federal Physician Self-Referral Statute

Paying physicians for referrals is a practice encouraged by Medicare. (T/F)

False; it is not encouraged, but in many cases prohibited (unless protected by safe harbor law)

Oversight of the compliance program is primarily the responsibility of the organization's general counsel. (T/F)

False; it is provided by the compliance officer and supported by compliance committee

If an overpayment is not returned to Medicare within 30 days, it becomes a violation of the False Claims Act. (T/F)

False; it must be returned to Medicare within 60 days, or it becomes a violation of FCA

All billing errors that result in overpayments by a federal healthcare program should be reported to the government through the Provider Self-Disclosure Protocol. (T/F)

False; it should be used for self-discovered cases of potential fraud

When a provider is excluded from federal healthcare programs, services he orders for a beneficiary of one of these programs will be paid as long as the service is furnished by a non-excluded provider. (T/F)

False; no payments will be given for an order from an excluded provider

The Stark Law is the government's primary litigation tool for combating fraud. (T/F)

False; the False Claims Act is the government's primary litigation tool for combating fraud

The federal government's primary approach to combating healthcare fraud is "pay and chase." (T/F)

False; they are moving away from "pay and chase" and moving towards prevention methods

The Medicare Fee-for-Service improper payment rate calculated through the Comprehensive Error Rate Testing (CERT) program is widely regarded to be an accurate reflection of the true size of the fraud, waste, and abuse problem. (T/F)

False; they are thought to understate the true size of the fraud, waste, and abuse problem

Services that are statutorily non-covered by Medicare can be located on the: - Medicare claim forms - list of CPT codes - Medicare non-covered services manual - Medicare notice of exclusions from Medicare benefits

Medicare notice of exclusions from Medicare benefits

The OIF is responsible for which of the following? - The privacy and security of health information - Reducing healthcare costs - Monitoring Medicare and Medicaid programs - Dictating that physicians cannot receive money for referring patients to a healthcare facility

Monitoring Medicare and Medicaid programs

CAC used which of the following processing to review the documentation in the EHR and assign a code number? - NLP - HL7 - POA - CPT

NLP

A corporate compliance program is an internal set of policies, processes, and procedures that an organization implements to help it act ethically and lawfully. (T/F)

True

An effective compliance program is a mitigating factor in reducing a provider's liability under fraud and abuse laws. (T/F)

True

Billing for services never rendered is one of the most common types of healthcare fraud. (T/F)

True

Detection of compliance violations is an important part of an effective compliance program. (T/F)

True

Mergers of healthcare organizations are subject to the Sherman Antitrust Act. (T/F)

True

Risk-sharing arrangements are a Stark Law exception to the referral prohibition. (T/F)

True

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) uses real-time data analysis to investigate healthcare fraud cases. (T/F)

True

The Patient Protection and Affordable Care Act added penalties for failing to report or return a known overpayment. (T/F)

True

The primary difference between fraud and abuse is intention. (T/F)

True

The seven fundamental elements of an effective compliance program recommended by the OIG are based on HHS regulatory standards. (T/F)

True

To fit within the Anti-Kickback Statute safe harbor for "electronic health records items and services," the software must be interoperable. (T/F)

True

True or False. The whistleblower provision of the False Claims Act is known as qui tam.

True

Waivers of the Stark Law, False Claims Act, and the Civil Monetary Penalties Law provision relating to beneficiary inducements apply to certain ACO arrangements. (T/F)

True

Some electronic health record features increase fraud and abuse risks. (T/F)

True; features such as copy and paste, creation of default notes, and templates can all lead to fraud and abuse risk

unbundling

a billing practice in which providers use multiple procedure codes for a group of procedures instead of the appropriate comprehensive code in order to inappropriately maximize reimbursement

corporate integrity agreement (CIA)

a compliance program imposed by the government that involves substantial government oversight and outside expert involvement in the organization's compliance activities and is generally required as a condition of settling a fraud and abuse investigation

fraud

a false representation of fact or a failure to disclose a fact that is material (relevant) to a healthcare transaction that results in damage to another party that reasonably relies on the misrepresentation or failure to disclose intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity, or some other party

Patient Protection and Affordable Care Act of 2010 (ACA)

a federal statute that was signed into law on March 23, 2010; along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010), the act is the product of the healthcare reform agenda of the Democratic 111th Congress and the Obama administration expanded the federal government's ability to combat fraud and abuse; required development and implementation of a corporate compliance program as a condition of enrollment in Medicare, Medicaid, and/or the Children's Health Insurance Program (CHIP), thus essentially making compliance programs mandatory rather than voluntary; required the HHS Secretary, in cooperation with the HHS Inspector General, to establish a voluntary, Medicare self-referral disclosure protocol that sets forth a process for providers and suppliers to self-disclose actual or potential violations of the Stark Law

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

a joint HHS and DOJ initiative to combat Medicare and Medicaid fraud; this team is using real-time data analysis to investigate healthcare fraud cases, rather than a prolonged subpoena and account analyses, resulting in much shorter periods of time between fraud identification, arrest and prosecution

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

a law enacted by Congress on August 21, 1996, governing various aspects of health information; federal legislation enacted to provide continuity of health coverage, control fraud and abuse in healthcare, reduce healthcare costs, and guarantee the security and privacy of health information

Deficit Reduction Act of 2005 (DRA)

a law enacted in 2006 that transformed the nature of compliance programs from voluntary to mandatory; failure to comply may result in the affected entity being ineligible to receive Medicaid payments

Federal Physician Self-Referral Statute/Stark Law

a law that prohibits physicians from ordering designated health services for Medicare (and to some extent Medicaid) patients from entities with which the physician or an immediate family member has a financial relationship

Provider Self-Disclosure Protocol

a mechanism for providers to voluntarily disclose self-discovered evidence of potential fraud to the OIG; this protocol gives providers the opportunity to avoid the costs and disruptions associated with a Federal investigation and civil or administrative litigation

knowing standard

a method of determining Federal Claims Act liability, requiring that the provider must have knowingly submitted the false claim

CMS Program Integrity Contractors

a nationally coordinated Medicare/Medicaid program integrity team of contractors - Zone Program Integrity Contractors (ZPICs) - Recovery Audit Contractors (RACs) - Medicaid Integrity Contractors (MICs) - National Benefit Integrity (NBI) Medicare Drug Integrity Contractor (MEDIC) - Supplemental Medical Review Contractor (SMRC)

corporate code of conduct

a part of the compliance plan that expresses the organization's commitment to ethical behavior

Federal Anti-Kickback Statute (AKS)

a statute that establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce business for which payment may be made under any federal healthcare program

Healthcare Fraud Prevention Partnership (HFPP)

a voluntary public-private partnership between the federal government, state officials, law enforcement, private health insurance plans and associations, and healthcare anti-fraud associations; foster a proactive approach to detect and prevent healthcare fraud through data and information sharing

qui tam

a whistleblower under the False Claim Act

safe habors

activities designated by the Office of Inspector General as not subject to prosecution and protect the organization from civil or criminal penalties protect certain payment and business practices that could potentially implicate the AKS from criminal and civil prosecution; to be protected by a safe harbor, an arrangement must fit squarely in the safe harbor and satisfy all of its requirements

compliance officer

an individual responsible for overseeing an organization's compliance program and ensuring that the program promotes ethical business practices and conformity to federal, state, and private payer program requirements

whistleblowers

an individual who discloses wrongdoing by an organization to the authorities or to the public

corporate compliance program

an internal set of policies, processes, and procedures that an organization implements to help it act ethically and lawfully; designed to establish a culture within a hospital that promotes prevention, detection, and resolution of instances of conduct that do not conform to federal and state law, and federal, state, and private payer healthcare program requirements, as well as the hospital's ethical and business policies programs that became common after the Federal Sentencing Guidelines reduced the fines and penalties to organizations found guilty of healthcare fraud if the organization has a fraud prevention and detection program in place; the programs also help organizations identify problems and improve performance

A systematic comparison of the products, services, and outcomes of one organization with those of a similar organization is the definition of which of the following? - unbundling - monitoring - benchmarking - key indicators

benchmarking

upcoding / overcoding

billing for services at a level of complexity that is higher than the service actually provided or documented

Recovery Audit Contractors (RACs)

carry out the mission of the Medicare Fee-for-Service Recovery Audit Program, which is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that CMS can implement actions that will prevent future improper payments

Supplemental Medical Review Contractor (SMRC)

charged with performing, and or providing support for, a variety of tasks aimed at lowering improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs

Health Care Fraud and Abuse Control (HCFAC)

designed to coordinate federal, state, and local law enforcement activities with respect to healthcare fraud and abuse; established by HIPAA, under the joint direction of the Attorney General and the Secretary of HHS acting through the Department's Inspector General

HIPAA and healthcare fraud

established a criminal federal offense of "healthcare fraud"; this statutory provision prohibits knowingly and willfully executing a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program, in connection with the delivery of or payment for healthcare benefits, items, or services; a person need not have actual knowledge of this section or specific intent to commit a violation; penalties may include fines, imprisonment, or both also expanded the OIG's sanction authorities; it extended the application and scope of the current civil monetary penalty and exclusion authorities beyond programs funded by HHS to all federal healthcare programs

Fraud Enforcement and Recovery Act of 2009 (FERA)

expands both the potential for liability under the False Claims Act (FCA) and the government's investigative powers, and it eliminates the requirement that a person has to present a false claim to a US government officer or employee, or a member of the US armed services, in order to be liable under the FCA

The OIG states that insufficient or missing documentation and which one of the following are responsible for 70% of bad claims submitted to Medicare? - unbundling of procedures - local coverage decisions - failure to document medical necessity - overcoding

failure to document medical necessity

Sherman Antitrust Act

first passed in 1890, one of several antitrust laws that collectively make it illegal to restrain trade through contracts or conspiracies and prohibit price fixing and mergers that lessen competition, enforced by the Federal Trade Commission (FTC) and the Department of Justice (DOJ) healthcare mergers and joint ventures among providers for the purchase of equipment are examples of arrangements that must be carefully reviewed to ensure that competition is not hindered and that consumers are not harmed

referral

for Medicare Part B services means "the request by a physician for the item or service", for all other Medicare and Medicaid services, "the request or establishment of a plan of care by a physician which includes the provision of the designated health service"

Accountable Care Organizations (ACOs)

groups of providers and suppliers meeting certain criteria that work together to manage and coordinate care for Medicare fee-for-service beneficiaries

improper payment

has been defined by the federal government as any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements

Zone Program Integrity Contractors (ZPICs)

investigate instances of suspected fraud, waste, and abuse in Medicare Parts A and B programs; seven

National Benefit Integrity (NBI) Medicare Drug Integrity Contractor (MEDIC)

investigates fraud, waste, and abuse in the Medicare Parts C and D programs

advisory opinions

opinions about the application of the Office of the Inspector General's fraud and abuse authorities to the requesting party's existing or proposed business arrangement

waste

over-utilization or inappropriate utilization of services and misuse of resources; not considered a criminal or intentional act

The OIG has specific compliance guidelines for all of the following entities except: - hospitals - home health agencies - pharmacies - hospices

pharmacies

Medicare Administrative Contractors (MACs)

private health plans that have been awarded a geographic jurisdiction to process Medicare Parts A and B medical claims or Durable Medical Equipment claims for Medicare Fee-for-Service beneficiaries

realtor

private persons who may enforce the False Claims Act by filing a complaint, under seal, alleging fraud committed against the government

The Stark Law: - prohibits physicians from billing for lab services - prohibits physicians from ordering lab services at hospitals - prohibits physicians from ordering tests on family members - prohibits physicians from ordering from entities that they have financial relationship

prohibits physicians from ordering from entities that they have financial relationship

abuse

provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices and that may directly or indirectly result in unnecessary costs to the program, improper payment, services that fail to meet professionally recognized standards of care or are medically unnecessary, or services that directly or indirectly result in adverse patient outcomes or delays in appropriate diagnosis or treatment

corporate compliance

refers to adherence to the laws and regulations passed by official regulating bodies as well as general principles of ethical conduct

Civil Monetary Penalties (CMP) law

section 1128A of the Social Security Act, passed in 1981 as one of several administrative remedies to combat increases in healthcare fraud and abuse, which authorizes the secretary and inspector general of the Department of Health and Human Services (HHS) to impose civil monetary penalties, assessment, and program exclusions on individuals and entities whose wrongdoing causes injury to HHS programs or their beneficiaries

Medicaid Integrity Contractors (MICs)

support state Medicaid program integrity efforts; conduct post-payment audits; and identify overpayments and refer them to states for collection; three types: review, audit, education

False Claims Act (FCA)

the government's primary litigation tool for combating fraud, which provides that anyone who "knowingly" submits false claims to the government is liable for damages up to three times the amount of the erroneous payment plus mandatory penalties between $5,500 and $11,000 for each false claim submitted

renumeration

the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind such as kickbacks, bribes, and rebates.

What are the damages for violations of the FCA?

violations of the FCA may result in damages up to three times the amount of the erroneous payment plus penalties up to $11,000 for each false claim submitted