CPE Regulatory & Legal Compliance 2 — Questions and Answers
Question 1: Under the False Claims Act, which standard of intent is required to establish liability for submitting a fraudulent claim to a federal healthcare program?
- Strict liability with no intent required
- Knowingly, recklessly, or with deliberate ignorance (Correct answer)
- Specific intent to defraud proven beyond reasonable doubt
- Negligence resulting in a billing error
Correct answer: Knowingly, recklessly, or with deliberate ignorance
The False Claims Act requires proof that the defendant acted knowingly, which includes actual knowledge, deliberate ignorance, or reckless disregard of the truth.
Question 2: A physician executive discovers that a employed physician has been upcoding E&M visits for two years. Which regulatory body is primarily responsible for investigating Medicare billing fraud of this nature?
- The Joint Commission
- Office of Inspector General (OIG) (Correct answer)
- Centers for Medicare & Medicaid Services Quality Improvement Organization
- State Medical Board
Correct answer: Office of Inspector General (OIG)
The OIG has primary responsibility for detecting and investigating fraud, waste, and abuse in Medicare and Medicaid programs.
Question 3: What is the maximum civil monetary penalty per false claim under the False Claims Act as periodically adjusted for inflation?
- $5,000 to $10,000 per claim
- $10,000 to $25,000 per claim
- $13,000 to $26,000 per claim (approximate current range) (Correct answer)
- $50,000 to $100,000 per claim
Correct answer: $13,000 to $26,000 per claim (approximate current range)
The FCA penalties are adjusted periodically for inflation; as of recent years, penalties range approximately $13,000–$26,000 per false claim, plus treble damages.
Question 4: Which Safe Harbor under the Anti-Kickback Statute protects payments made to bona fide employees of a healthcare entity?
- Investment interests safe harbor
- Employee safe harbor (Correct answer)
- Personal services and management contracts safe harbor
- Referral services safe harbor
Correct answer: Employee safe harbor
The employee safe harbor protects remuneration paid by an employer to a bona fide employee for furnishing covered items or services.
Question 5: A hospital is conducting a self-disclosure to the OIG regarding potential violations. Which program allows healthcare providers to voluntarily self-disclose conduct that may violate the AKS or other fraud statutes?
- Compliance Assistance Program (CAP)
- Provider Self-Disclosure Protocol (SDP) (Correct answer)
- Corporate Integrity Agreement (CIA) Pathway
- Voluntary Corrective Action Program (VCAP)
Correct answer: Provider Self-Disclosure Protocol (SDP)
The OIG's Provider Self-Disclosure Protocol allows providers to voluntarily identify, disclose, and resolve instances of potential fraud.
Question 6: Under EMTALA, how long must a hospital retain medical records related to an individual who came to the emergency department?
- 3 years from the date of service
- 5 years from the date of service, or until the patient is 21 if a minor (Correct answer)
- 7 years from the date of service
- 10 years from the date of service
Correct answer: 5 years from the date of service, or until the patient is 21 if a minor
EMTALA requires hospitals to retain medical records related to individuals who present to the emergency department for five years, or until the minor reaches age 21.
Question 7: Which legal doctrine holds that a hospital may be vicariously liable for the negligence of an independent contractor physician if the patient reasonably believed the physician was a hospital employee?
- Res ipsa loquitur
- Corporate negligence
- Ostensible agency (apparent authority) (Correct answer)
- Respondeat superior
Correct answer: Ostensible agency (apparent authority)
Ostensible agency doctrine makes hospitals liable for independent contractors when patients reasonably believed they were receiving care from hospital employees.
CPE Regulatory & Legal Compliance 2
Under the False Claims Act, which standard of intent is required to establish liability for submitting a fraudulent claim to a federal healthcare program?