Healthcare Fraud and Abuse Flashcards

A medical device company offers a physician a paid speaking engagement. The payment is significantly above fair market value and the physician is expected to predominantly use the company's devices. Which federal law is most likely implicated by this arrangement?

Answer: The Anti-Kickback Statute (AKS)

The Anti-Kickback Statute (AKS) is a criminal law that prohibits knowingly and willfully offering or receiving remuneration (anything of value) to induce or reward referrals for items or services payable by federal healthcare programs. The excessive payment for the speaking engagement could be seen as a way to reward the physician for using the company's devices, which would generate business paid for by programs like Medicare or Medicaid.

A hospital compliance officer discovers that a billing department employee has been intentionally using incorrect billing codes ('upcoding') to receive higher reimbursements from Medicare for the past year. Under which law can a private individual, such as a whistleblower, file a lawsuit on behalf of the government?

Answer: The False Claims Act (FCA)

The False Claims Act (FCA) contains a 'qui tam' provision that allows private citizens with knowledge of fraud against the government to file a lawsuit on the government's behalf. If successful, the whistleblower, known as a relator, can receive a portion of the recovered funds. Upcoding is a classic example of a false claim submitted for government payment.

Which of the following situations would trigger a mandatory exclusion from participation in all Federal health care programs by the Office of Inspector General (OIG)?

Answer: A felony conviction for Medicare fraud.

The OIG is required by law to exclude individuals and entities convicted of certain criminal offenses. These mandatory exclusions include felony convictions for Medicare or Medicaid fraud, patient abuse or neglect, and other healthcare-related felonies. The other options are grounds for permissive exclusion, where the OIG has discretion.

A radiologist has an ownership interest in a standalone imaging center. She refers her Medicare patients to this center for all their MRI needs. This arrangement, without a specific exception, would most likely violate which law?

Answer: The Stark Law (Physician Self-Referral Law)

The Stark Law is a strict liability statute that prohibits physicians from referring patients for 'designated health services' (like MRIs) payable by Medicare or Medicaid to an entity with which the physician has a financial relationship, unless an exception applies. Intent does not matter for a Stark Law violation.

What is the key distinction between healthcare 'fraud' and 'abuse'?

Answer: The intent and knowledge of the individual committing the act.

The primary difference between fraud and abuse is intent. Fraud involves an intentional deception or misrepresentation that the individual knows to be false and that could result in an unauthorized benefit. Abuse involves actions that may result in unnecessary costs to federal healthcare programs but are not the result of knowing and willful misconduct.

A compliance technician is reviewing a proposed agreement with a local home health agency. The hospital would provide the agency with free office space within the hospital in exchange for the agency accepting all of the hospital's patient referrals. Which of the following is the PRIMARY compliance concern with this arrangement?

Answer: Potential violation of the Anti-Kickback Statute.

The Anti-Kickback Statute (AKS) prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of items or services payable by a federal health care program. Providing free rent (something of value) in exchange for referrals would be a classic example of a potential kickback arrangement designed to generate business.