Healthcare Fraud, Waste & Abuse Prevention Flashcards

Which federal law specifically prohibits knowingly submitting false or fraudulent claims to the federal government, including Medicare and Medicaid?

Answer: False Claims Act

The False Claims Act (31 U.S.C. § 3729) is the primary federal law prohibiting submission of false claims to government programs and includes qui tam provisions allowing whistleblowers to file suits on the government's behalf.

A provider bills Medicare for a Level 4 office visit when the documentation only supports a Level 2 visit. This is an example of:

Answer: Upcoding

Upcoding is the fraudulent practice of billing for a higher-level or more expensive service than was actually documented or provided.

Which federal office serves as the primary investigative and enforcement body for Medicare and Medicaid fraud and abuse?

Answer: HHS Office of Inspector General (OIG)

The HHS Office of Inspector General (OIG) is the primary federal agency charged with fighting fraud, waste, and abuse in Medicare and Medicaid programs.

The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from:

Answer: Referring patients for designated health services to entities in which the physician has a financial interest

The Stark Law prohibits physicians from referring patients to receive designated health services payable by Medicare or Medicaid from an entity with which the physician or an immediate family member has a financial relationship.

Under the False Claims Act, when the government intervenes in a qui tam lawsuit, what percentage of recovered funds may the whistleblower (relator) receive?

Answer: 15–25%

When the government intervenes in a qui tam case, the relator is entitled to receive 15–25% of the recovered proceeds; if the government does not intervene, the relator may receive 25–30%.

Billing Medicare for a surgical procedure that was never actually performed on a patient is an example of:

Answer: Phantom billing

Phantom billing (billing for services not rendered) involves submitting claims for procedures, services, or supplies that were never actually provided to the patient.

Which of the following best defines 'medical necessity' in the context of healthcare fraud prevention?

Answer: Services must be clinically appropriate and required for the diagnosis or treatment of illness or injury

Medical necessity means services must be clinically appropriate, reasonable, and necessary for diagnosis or treatment; billing for services that are not medically necessary is considered fraud.