CHC Healthcare Fraud and Abuse 4 — Questions and Answers
Question 1: The OIG's List of Excluded Individuals and Entities (LEIE) is significant for healthcare compliance programs primarily because:
- It lists all providers who have been investigated but not charged
- Entities that employ or pay excluded individuals may be subject to civil monetary penalties (Correct answer)
- Exclusion from the LEIE automatically triggers loss of a provider's state medical license
- It applies only to individuals excluded for fraud, not for quality-of-care violations
Correct answer: Entities that employ or pay excluded individuals may be subject to civil monetary penalties
Organizations that employ or contract with LEIE-excluded individuals for services paid by federal healthcare programs can face significant civil monetary penalties.
Question 2: A surgeon performs a procedure and separately bills for pre- and post-operative care that is normally included in the global surgical package. This billing practice is known as:
- Upcoding
- Unbundling (Correct answer)
- Duplicate billing
- Balance billing
Correct answer: Unbundling
Unbundling means billing separately for services that are components of a global service package that should be billed as a single comprehensive code.
Question 3: Which of the following is NOT one of the OIG's seven elements of an effective compliance program?
- Implementing written policies and procedures
- Conducting effective training and education
- Requiring a board-approved annual compliance audit by external counsel (Correct answer)
- Responding promptly to detected offenses and taking corrective action
Correct answer: Requiring a board-approved annual compliance audit by external counsel
The OIG's seven elements do not specifically require an annual external audit by board-approved counsel; they focus on internal oversight, training, auditing, and response mechanisms.
Question 4: A provider who has been excluded from Medicare and Medicaid is later found to have been practicing and billing during the exclusion period. Which of the following outcomes is most likely?
- The provider will only face re-exclusion with no additional penalties
- The provider may face civil monetary penalties and an extended exclusion period (Correct answer)
- The provider must repay overpayments but faces no criminal liability
- The provider's exclusion is automatically converted to a voluntary withdrawal
Correct answer: The provider may face civil monetary penalties and an extended exclusion period
Billing federal programs while excluded exposes the provider to civil monetary penalties, potential criminal prosecution, and extended or permanent exclusion.
Question 5: Which of the following scenarios most likely implicates the 'one-purpose test' applied to Anti-Kickback Statute analysis?
- A hospital pays a physician fair market value for administrative services under a written agreement
- A vendor provides free consulting services to a hospital, hoping the hospital will purchase its products (Correct answer)
- A physician group shares profits equally among all partners regardless of referral volume
- A pharmaceutical company sponsors an accredited CME program open to all physicians
Correct answer: A vendor provides free consulting services to a hospital, hoping the hospital will purchase its products
Under the one-purpose test, if one purpose of the remuneration is to induce referrals or purchases, the AKS is violated — even if there are legitimate business reasons too.
Question 6: A compliance officer discovers that a physician has been receiving monthly payments from a medical device company with no documented services being performed. The FIRST recommended action is:
- Immediately terminate the physician's contract without investigation
- Conduct a prompt internal investigation to determine the nature and extent of the issue (Correct answer)
- Report the arrangement to the OIG before conducting any internal review
- Suspend Medicare billing for all procedures involving that device
Correct answer: Conduct a prompt internal investigation to determine the nature and extent of the issue
Best practice and OIG guidance call for a prompt, thorough internal investigation before taking action or making external reports, to understand the full scope of the issue.
Question 7: Under the Affordable Care Act, providers must report and return Medicare overpayments within how many days of identifying the overpayment?
- 30 days
- 60 days (Correct answer)
- 90 days
- 180 days
Correct answer: 60 days
The ACA's 60-day rule requires providers to report and return identified Medicare and Medicaid overpayments within 60 days of identification, or the retained overpayment becomes a false claim.
CHC Healthcare Fraud and Abuse 4
The OIG's List of Excluded Individuals and Entities (LEIE) is significant for healthcare compliance programs primarily because: