CHC Healthcare Fraud and Abuse 5 — Questions and Answers
Question 1: Which of the following arrangements would most likely qualify for the Anti-Kickback Statute 'employment safe harbor'?
- An independent contractor paid per referral made to the hospital
- A bona fide employee receiving a salary not based on referral volume (Correct answer)
- A per diem medical director paid per patient referred to surgery
- A consultant paid based on the value of business generated
Correct answer: A bona fide employee receiving a salary not based on referral volume
The employment safe harbor protects compensation paid by an employer to a bona fide employee for services in the employer's business, provided it is not based on the volume or value of referrals.
Question 2: A compliance program audit reveals that a physician is billing Evaluation & Management (E&M) level 5 codes for almost all patient encounters. This pattern is BEST described as a potential indicator of:
- Phantom billing
- Unbundling
- Upcoding (Correct answer)
- Duplicate billing
Correct answer: Upcoding
Consistently billing the highest-level E&M codes regardless of the complexity of patient encounters is a classic pattern of upcoding.
Question 3: The term 'medically unnecessary services' in the context of healthcare fraud most commonly refers to:
- Services covered by Medicare but not Medicaid
- Services provided and billed that do not meet accepted standards of medical practice for the patient's condition (Correct answer)
- Services provided by a specialist that could have been provided by a primary care physician
- Services furnished in a hospital outpatient setting instead of a physician's office
Correct answer: Services provided and billed that do not meet accepted standards of medical practice for the patient's condition
Billing for medically unnecessary services means billing for procedures or tests that are not reasonable and necessary for the patient's diagnosis or treatment under accepted clinical standards.
Question 4: A whistleblower files a qui tam lawsuit under the False Claims Act. The government decides to intervene. What percentage of the total recovery can the relator (whistleblower) generally receive?
- 1–5%
- 10–25% (if the government intervenes) or 25–30% (if the government declines) (Correct answer)
- 15–30%
- Up to 50%
Correct answer: 10–25% (if the government intervenes) or 25–30% (if the government declines)
Under the FCA, relators in government-intervened cases receive 15–25% of the recovery; if the government declines and the relator proceeds alone, the share is 25–30%.
Question 5: Which of the following is an example of 'credit card skimming' adapted to the healthcare context — i.e., a practice that involves billing the same service to multiple payers?
- Upcoding
- Duplicate billing (Correct answer)
- Bundling
- Cost-shifting
Correct answer: Duplicate billing
Duplicate billing involves submitting the same claim more than once to the same or different payers to receive multiple payments for a single service.
Question 6: Under CMS's Medicare Fraud Prevention program, which tool allows Medicare beneficiaries to review their own claim data to identify potential fraud?
- The OIG LEIE database
- The Medicare Summary Notice (MSN) or MyMedicare.gov account (Correct answer)
- The National Practitioner Data Bank (NPDB)
- The CMS Provider Enrollment database
Correct answer: The Medicare Summary Notice (MSN) or MyMedicare.gov account
Medicare beneficiaries can review their claims through the Medicare Summary Notice or their MyMedicare.gov account to spot services they did not receive.
Question 7: A hospital compliance officer is reviewing an arrangement where physicians receive 'facility fees' for office visits conducted in a newly designated provider-based department. The PRIMARY compliance concern is:
- Whether the physicians have documented the visits in the electronic health record
- Whether the provider-based designation meets CMS requirements and whether patients are properly notified of additional costs (Correct answer)
- Whether the department is accredited by The Joint Commission
- Whether the physicians have completed annual billing compliance training
Correct answer: Whether the provider-based designation meets CMS requirements and whether patients are properly notified of additional costs
Provider-based billing allows facilities to charge facility fees, but CMS has strict requirements for provider-based status, and improper designation or lack of patient notification can constitute fraud.
CHC Healthcare Fraud and Abuse 5
Which of the following arrangements would most likely qualify for the Anti-Kickback Statute 'employment safe harbor'?