CCT Healthcare Fraud and Abuse 5 — Questions and Answers
Question 1: A hospital enters a management services agreement with a physician group and pays above-fair-market-value fees. This arrangement raises concerns primarily under which statute?
- HIPAA
- Anti-Kickback Statute (Correct answer)
- Emergency Medical Treatment and Labor Act
- Health Information Technology for Economic and Clinical Health Act
Correct answer: Anti-Kickback Statute
Payments above fair market value in management or service agreements can constitute illegal remuneration under the AKS if they are intended to induce referrals of federal healthcare program business.
Question 2: Under the False Claims Act, what is the meaning of 'reverse false claims'?
- Claims submitted by government contractors rather than healthcare providers
- Knowingly avoiding or concealing an obligation to pay money to the government (Correct answer)
- Claims that are corrected and resubmitted after an audit
- Whistleblower lawsuits filed against the government
Correct answer: Knowingly avoiding or concealing an obligation to pay money to the government
The 2009 Fraud Enforcement and Recovery Act clarified that reverse false claims cover situations where a person knowingly conceals or improperly avoids a financial obligation owed to the government, such as failing to return overpayments.
Question 3: A compliance officer receives a hotline report that a sales representative is providing free meals exceeding $150 to physicians weekly. The first step should be to:
- Immediately terminate the sales representative
- Notify the OIG before conducting an internal review
- Conduct a prompt and thorough internal investigation (Correct answer)
- Advise the physicians to self-report to CMS
Correct answer: Conduct a prompt and thorough internal investigation
Best practice requires the compliance officer to promptly investigate the allegation through a structured internal review before taking disciplinary action or external reporting.
Question 4: Which exception to Stark Law allows physicians to refer patients to an entity for designated health services if those services are provided within the physician's own practice?
- Fair market value exception
- Bona fide employment exception
- In-office ancillary services exception (Correct answer)
- Rural provider exception
Correct answer: In-office ancillary services exception
The in-office ancillary services exception permits physicians to refer within their own group practice for certain designated health services if specific supervision, location, and billing requirements are met.
Question 5: What is the significance of the '60-day rule' in healthcare compliance?
- Providers must report new billing codes within 60 days of use
- Identified Medicare/Medicaid overpayments must be reported and returned within 60 days (Correct answer)
- Corporate integrity agreements must be signed within 60 days of settlement
- OIG investigations must be completed within 60 days of initiation
Correct answer: Identified Medicare/Medicaid overpayments must be reported and returned within 60 days
Under the ACA and CMS regulations, once a provider identifies a Medicare or Medicaid overpayment, it must be reported and returned within 60 days or it may become a false claim under the FCA.
Question 6: Which federal agency operates the Medicare Strike Force, which uses data analytics to detect and prosecute healthcare fraud?
- OIG and DOJ jointly (Correct answer)
- CMS Office of Program Integrity
- FBI Healthcare Fraud Unit
- HHS Office of Civil Rights
Correct answer: OIG and DOJ jointly
The Medicare Strike Force is a joint initiative of the OIG and DOJ that uses advanced data analytics to identify aberrant billing patterns and deploys multi-agency teams to high-fraud cities.
Question 7: A durable medical equipment (DME) supplier bills Medicare for power wheelchairs for patients who are ambulatory and do not have a documented medical need. This scheme is best classified as:
- Upcoding
- Medically unnecessary services fraud (Correct answer)
- Unbundling
- Stark Law violation
Correct answer: Medically unnecessary services fraud
Billing for items or services that are not medically necessary constitutes false claims fraud because Medicare only covers items and services that are reasonable and necessary for diagnosis or treatment.
CCT Healthcare Fraud and Abuse 5
A hospital enters a management services agreement with a physician group and pays above-fair-market-value fees.
This arrangement raises concerns primarily under which statute?