Healthcare Compliance Fundamentals Flashcards
6 cards from real HMCC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Healthcare Compliance Fundamentals flashcards as text
What is the False Claims Act and how does it apply to healthcare?
Answer: A federal law imposing liability on persons who defraud governmental programs, including submitting false claims for healthcare reimbursement
The False Claims Act imposes civil liability for knowingly submitting false or fraudulent claims for payment to federal healthcare programs. Violations can result in treble damages plus per-claim penalties.
What is a qui tam provision?
Answer: A provision in the False Claims Act allowing private citizens (whistleblowers) to file lawsuits on behalf of the government and share in recovered funds
Qui tam (from Latin 'who sues on behalf of the king') allows individuals with knowledge of fraud to file suit against the fraudster. Successful whistleblowers receive 15-30% of recovered funds.
What is the Sunshine Act (Open Payments Program)?
Answer: A federal law requiring pharmaceutical and medical device companies to report payments and transfers of value to physicians and teaching hospitals
The Physician Payments Sunshine Act requires manufacturers to report payments, gifts, meals, speaking fees, and research funding to physicians and teaching hospitals, with data publicly available on CMS's Open Payments website.
What is a Corporate Integrity Agreement (CIA)?
Answer: A binding agreement between OIG and a healthcare entity resolving fraud allegations, requiring specific compliance measures for a set period
CIAs are negotiated settlements requiring organizations to implement specific compliance obligations (independent review, training, reporting) typically for 5 years, as an alternative to exclusion from federal healthcare programs.
What is EMTALA and what does it require?
Answer: The Emergency Medical Treatment and Labor Act requiring hospitals with emergency departments to provide screening examinations and stabilizing treatment regardless of ability to pay
EMTALA requires Medicare-participating hospitals with emergency departments to provide medical screening exams and stabilizing treatment to anyone regardless of insurance status, citizenship, or ability to pay.
What are the penalties for HIPAA violations?
Answer: Civil penalties ranging from $100 to $50,000+ per violation (capped at $1.5M per year), plus potential criminal penalties including imprisonment
HIPAA enforcement includes tiered civil penalties based on the level of negligence, plus criminal penalties for knowing violations (up to $250,000 and 10 years imprisonment for violations committed for commercial advantage).