CHC - Certified in Healthcare Compliance Healthcare Fraud and Abuse Questions and Answers — Questions and Answers
Question 1: A hospital provides a physician with free office space in a medical office building it owns. The physician, in turn, refers a significant number of Medicare patients to the hospital for various services. This arrangement is not structured to fit within any safe harbor. Which of the following federal laws is most likely implicated by this arrangement?
- The Health Insurance Portability and Accountability Act (HIPAA)
- The Emergency Medical Treatment and Labor Act (EMTALA)
- The Anti-Kickback Statute (AKS) (Correct answer)
- The Civil Monetary Penalties Law (CMPL)
Correct answer: The Anti-Kickback Statute (AKS)
The Anti-Kickback Statute (AKS) is a criminal law that prohibits the knowing and willful exchange of anything of value (remuneration) to induce or reward referrals for items or services payable by federal healthcare programs. The free office space is considered remuneration, and its provision in exchange for patient referrals directly implicates the AKS. While violations could lead to CMPL penalties, the core issue described is a potential kickback.
Question 2: A key distinction between the Stark Law and the Anti-Kickback Statute (AKS) is that the Stark Law:
- applies only to referrals made by physicians for designated health services (DHS). (Correct answer)
- requires proof of specific intent to violate the law for penalties to be imposed.
- carries both criminal and civil penalties for violations.
- is enforced exclusively by the Department of Justice (DOJ).
Correct answer: applies only to referrals made by physicians for designated health services (DHS).
The Stark Law is more narrowly focused than the AKS. It specifically prohibits physicians from referring Medicare or Medicaid patients for 'designated health services' to entities with which they (or an immediate family member) have a financial relationship, unless an exception applies. The AKS applies more broadly to any remuneration for referrals of any federal healthcare business and is not limited to physicians or DHS.
Question 3: An employee in a hospital's billing department discovers a systematic software error that has caused the hospital to 'upcode' claims for a specific outpatient procedure for the past two years, resulting in significant overpayments from Medicare. Under the False Claims Act (FCA), what is the employee's best course of action to report this and potentially receive a percentage of the recovery?
- Report the issue to the local news media to create public pressure.
- File a 'qui tam' lawsuit on behalf of the government. (Correct answer)
- Anonymously report the issue directly to the hospital's CEO.
- Wait for a government audit to discover the error independently.
Correct answer: File a 'qui tam' lawsuit on behalf of the government.
The False Claims Act includes 'qui tam' provisions that allow a private individual, known as a relator, to file a lawsuit on behalf of the United States government. If the lawsuit is successful, the relator is entitled to a percentage of the funds recovered. This is the formal mechanism for a whistleblower to report fraud and be eligible for a reward under the FCA.
Question 4: The Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in federal healthcare programs. Which of the following would trigger a MANDATORY exclusion?
- A misdemeanor conviction for healthcare fraud.
- Suspension of a medical license for professional incompetence.
- A felony conviction for patient abuse or neglect. (Correct answer)
- Defaulting on a federal health education loan.
Correct answer: A felony conviction for patient abuse or neglect.
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 listed are grounds for a permissive exclusion, where the OIG has discretion.
Question 5: A diagnostic imaging center owned by a group of physicians refers its Medicare patients exclusively to an affiliated physical therapy practice in which the same physicians also hold an ownership interest. To comply with the Stark Law, this financial relationship must:
- be verbally agreed upon by all physician-owners.
- generate less than $5,000 per year in revenue from referrals.
- be reported to the local medical society.
- fit squarely within a designated statutory or regulatory exception. (Correct answer)
Correct answer: fit squarely within a designated statutory or regulatory exception.
The Stark Law prohibits physician self-referrals for designated health services (like physical therapy) to entities where they have a financial interest. The law is a strict liability statute, meaning intent is not a factor. For the arrangement to be permissible, it must satisfy all requirements of a specific exception, such as the in-office ancillary services exception.
Question 6: Which of the following best describes the 'knowing' standard under the civil False Claims Act (FCA)?
- The individual must have a specific intent to defraud the government.
- The individual must have actual knowledge of the falsity of the information.
- The individual acted with deliberate ignorance or reckless disregard of the truth. (Correct answer)
- The individual was negligent in failing to verify the information's accuracy.
Correct answer: The individual acted with deliberate ignorance or reckless disregard of the truth.
The FCA defines 'knowing' broadly. It does not require proof of a specific intent to defraud. Liability can be established if a person has actual knowledge, or if they act in 'deliberate ignorance' or 'reckless disregard' of the truth or falsity of the information related to the claim.
CHC - Certified in Healthcare Compliance Healthcare Fraud and Abuse Questions and Answers
A hospital provides a physician with free office space in a medical office building it owns.
The physician, in turn, refers a significant number of Medicare patients to the hospital for various services.
This arrangement is not structured to fit within any safe harbor.
Which of the following federal laws is most likely implicated by this arrangement?