CCT Healthcare Fraud and Abuse 3 — Questions and Answers
Question 1: What is the 'qui tam' provision of the False Claims Act?
- A government audit process for Medicare claims
- A provision allowing private citizens to sue on behalf of the government and share in recoveries (Correct answer)
- A whistleblower protection clause for federal employees only
- A mandatory reporting requirement for healthcare providers
Correct answer: A provision allowing private citizens to sue on behalf of the government and share in recoveries
The qui tam provision allows private individuals (relators) to file sealed lawsuits alleging FCA violations on behalf of the government and receive 15–30% of any recovered proceeds.
Question 2: A home health agency bills Medicare for skilled nursing visits that were never performed. This is an example of:
- Unbundling
- Phantom billing (Correct answer)
- Upcoding
- Waiver of cost-sharing
Correct answer: Phantom billing
Phantom billing (billing for services not rendered) occurs when a provider submits claims for services that were never actually provided to the patient.
Question 3: Under Stark Law, which of the following is a 'designated health service' subject to the physician self-referral prohibition?
- Primary care office visits
- Clinical laboratory services (Correct answer)
- Telehealth consultations
- Preventive care screenings
Correct answer: Clinical laboratory services
Clinical laboratory services are one of the eleven designated health services (DHS) listed under Stark Law to which the self-referral prohibition applies.
Question 4: What government agency is primarily responsible for investigating healthcare fraud in the Medicare and Medicaid programs?
- Centers for Medicare & Medicaid Services (CMS)
- Office of Inspector General (OIG) (Correct answer)
- Department of Justice (DOJ)
- Health Resources and Services Administration (HRSA)
Correct answer: Office of Inspector General (OIG)
The OIG of HHS is the primary federal agency responsible for detecting and investigating fraud, waste, and abuse in Medicare, Medicaid, and other HHS programs.
Question 5: A provider routinely waives Medicare copayments for all patients without determining financial need. This practice may violate the Anti-Kickback Statute because:
- It reduces provider revenue unnecessarily
- Routine waivers can induce patients to select providers based on financial benefit (Correct answer)
- CMS requires all copayments to be collected
- It violates patient financial privacy rights
Correct answer: Routine waivers can induce patients to select providers based on financial benefit
Routine waiver of Medicare cost-sharing can constitute illegal remuneration under the AKS by inducing beneficiaries to choose providers based on the financial benefit rather than clinical judgment.
Question 6: Which safe harbor under the Anti-Kickback Statute protects properly structured investment interests in publicly traded companies?
- The personal services safe harbor
- The investment interests safe harbor (Correct answer)
- The group purchasing organization safe harbor
- The employee safe harbor
Correct answer: The investment interests safe harbor
The investment interests safe harbor protects returns on equity investments in large publicly traded entities or certain small entities that meet specific ownership and revenue criteria.
Question 7: What does 'unbundling' mean in healthcare billing fraud?
- Billing for services provided as part of a package at the standard bundled rate
- Separately billing for services that should be billed together under a single comprehensive code (Correct answer)
- Combining multiple patient encounters into one claim
- Submitting claims to multiple payers for the same service
Correct answer: Separately billing for services that should be billed together under a single comprehensive code
Unbundling involves billing separately for individual components of a procedure that should be billed as a single, combined code, resulting in higher total reimbursement.
CCT Healthcare Fraud and Abuse 3
What is the 'qui tam' provision of the False Claims Act?