CFO Regulatory Compliance & Legal Framework 3 — Questions and Answers
Question 1: The Anti-Kickback Statute (AKS) prohibits orthotists from doing which of the following?
- Charging patients more than Medicare's allowed amount
- Offering free services to attract federally insured patients (Correct answer)
- Billing for services not yet rendered
- Sharing patient records without consent
Correct answer: Offering free services to attract federally insured patients
The AKS prohibits offering, paying, soliciting, or receiving anything of value to induce referrals of items or services covered by federal healthcare programs.
Question 2: Which accreditation body is most commonly recognized by CMS for DMEPOS suppliers seeking Medicare accreditation?
- The Joint Commission (TJC)
- ACHC (Accreditation Commission for Health Care) (Correct answer)
- CARF International
- National Committee for Quality Assurance (NCQA)
Correct answer: ACHC (Accreditation Commission for Health Care)
ACHC is one of the CMS-approved accreditation organizations for DMEPOS suppliers, alongside HQAA and BOC.
Question 3: A state's orthotics practice act requires licensure for independent practice. An orthotist who practices without a license in that state is subject to which consequence?
- Only a written warning for the first offense
- Civil and/or criminal penalties depending on state law (Correct answer)
- Loss of ABC or BOC certification only
- Mandatory re-education but no legal penalty
Correct answer: Civil and/or criminal penalties depending on state law
Practicing without a required state license can result in civil fines, criminal charges, and cease-and-desist orders depending on state statutes.
Question 4: Under Medicare's competitive bidding program for DMEPOS, which category of orthotic items is currently subject to competitive bidding?
- Custom-fabricated spinal orthoses
- Off-the-shelf knee braces in designated areas (Correct answer)
- All prosthetic devices
- Custom shoe inserts for diabetes
Correct answer: Off-the-shelf knee braces in designated areas
Certain off-the-shelf orthoses, including some knee braces, have been included in competitive bidding areas under Medicare's DMEPOS Competitive Bidding Program.
Question 5: Which document must accompany a Medicare claim for a custom-fabricated orthosis to demonstrate medical necessity?
- A signed patient satisfaction survey
- A detailed written order (prescription) from the treating physician (Correct answer)
- A manufacturer's product catalog entry
- Proof of prior authorization from a private insurer
Correct answer: A detailed written order (prescription) from the treating physician
Medicare requires a detailed written order signed by the prescribing physician establishing medical necessity before an orthotic device is provided.
Question 6: The False Claims Act allows private citizens (relators) to file lawsuits on behalf of the government in cases of Medicare fraud. This type of lawsuit is called a:
- Class action suit
- Qui tam lawsuit (Correct answer)
- Writ of mandamus
- Declaratory judgment action
Correct answer: Qui tam lawsuit
Qui tam provisions of the False Claims Act permit private individuals (whistleblowers) to sue on the government's behalf and share in any recovery.
Question 7: When must a DMEPOS supplier obtain a Certificate of Medical Necessity (CMN) from the ordering physician for certain Medicare-covered orthoses?
- Only when the item costs more than $500
- As specified by CMS for items that require a CMN under coverage policy (Correct answer)
- For every orthotic claim regardless of complexity
- Only for items dispensed in competitive bidding areas
Correct answer: As specified by CMS for items that require a CMN under coverage policy
CMS specifies which DMEPOS items require a CMN; suppliers must obtain it from the prescribing physician as a condition of Medicare payment.
CFO Regulatory Compliance & Legal Framework 3
The Anti-Kickback Statute (AKS) prohibits orthotists from doing which of the following?