CCT Healthcare Fraud and Abuse 4 — Questions and Answers
Question 1: A Corporate Integrity Agreement (CIA) is typically entered into between a healthcare provider and which government agency?
- Centers for Medicare & Medicaid Services
- Office of Inspector General (OIG) (Correct answer)
- Department of Justice
- Federal Trade Commission
Correct answer: Office of Inspector General (OIG)
CIAs are negotiated between healthcare providers and the OIG as part of civil settlement agreements, requiring the provider to implement compliance measures in exchange for continued program participation.
Question 2: Under the Exclusion Statute, what is the minimum mandatory exclusion period for an individual convicted of a felony related to Medicare or Medicaid fraud?
- 1 year
- 3 years
- 5 years (Correct answer)
- 10 years
Correct answer: 5 years
42 U.S.C. § 1320a-7(a) requires a minimum 5-year mandatory exclusion for individuals convicted of program-related crimes, patient abuse, or felony drug offenses.
Question 3: Which element distinguishes 'fraud' from 'abuse' in federal healthcare program enforcement?
- The dollar amount of improper billing
- Intentional deception or misrepresentation versus inadvertent billing errors (Correct answer)
- Whether the conduct involves Medicare versus Medicaid
- The type of service billed incorrectly
Correct answer: Intentional deception or misrepresentation versus inadvertent billing errors
Healthcare fraud requires intentional deception or misrepresentation to obtain unauthorized benefits, while abuse involves practices that are inconsistent with sound business or medical practices but may lack criminal intent.
Question 4: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created to:
- Administer Medicare Part D drug benefits
- Coordinate joint DOJ and HHS efforts to combat Medicare and Medicaid fraud (Correct answer)
- Certify compliance officers in the healthcare industry
- Audit hospital billing systems for CMS
Correct answer: Coordinate joint DOJ and HHS efforts to combat Medicare and Medicaid fraud
HEAT is a joint initiative between the DOJ and HHS that coordinates federal efforts to prevent fraud, waste, and abuse in Medicare and Medicaid through Strike Force teams and data analytics.
Question 5: A physician refers patients exclusively to a lab in which he owns a 15% equity stake. Under Stark Law, this arrangement:
- Is permissible because the ownership is below 20%
- Triggers the self-referral prohibition regardless of ownership percentage (Correct answer)
- Is protected under the in-office ancillary services exception
- Requires disclosure to CMS but is otherwise allowed
Correct answer: Triggers the self-referral prohibition regardless of ownership percentage
Stark Law prohibits referrals to entities in which the physician (or immediate family) has any financial relationship, including any ownership interest, without a qualifying exception.
Question 6: What is the primary purpose of the OIG's Work Plan?
- To set Medicare reimbursement rates for the upcoming year
- To identify OIG audit and investigation priorities for the healthcare industry (Correct answer)
- To establish new Anti-Kickback Statute safe harbors
- To approve corporate integrity agreements
Correct answer: To identify OIG audit and investigation priorities for the healthcare industry
The OIG Work Plan outlines the audits, evaluations, and investigations the OIG plans to undertake during the year, helping providers identify areas of heightened scrutiny.
Question 7: Which type of Medicare fraud scheme involves a provider billing for a more expensive brand-name drug while dispensing a less expensive generic?
- Upcoding
- Drug diversion
- Prescription drug substitution fraud (Correct answer)
- Double billing
Correct answer: Prescription drug substitution fraud
Prescription drug substitution fraud occurs when a pharmacist or provider bills for a higher-cost drug but dispenses a cheaper substitute, pocketing the reimbursement difference.
CCT Healthcare Fraud and Abuse 4
A Corporate Integrity Agreement (CIA) is typically entered into between a healthcare provider and which government agency?