NCICS Healthcare Fraud, Waste & Abuse Prevention 2 — Questions and Answers
Question 1: The Anti-Kickback Statute (AKS) prohibits which of the following activities?
- Physicians referring patients to other medical specialties
- Offering or receiving anything of value to induce or reward referrals for services covered by federal healthcare programs (Correct answer)
- Billing Medicare for services not covered under the patient's benefit plan
- Using unlicensed staff to provide medical services
Correct answer: Offering or receiving anything of value to induce or reward referrals for services covered by federal healthcare programs
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals or generate business reimbursable by federal healthcare programs.
Question 2: A hospital bills Medicare separately for each component of a complex procedure—such as the procedure itself, radiologist interpretation, and supplies—when a single comprehensive CPT code should cover all components. This is known as:
- Upcoding
- Unbundling (Correct answer)
- Downcoding
- Double billing
Correct answer: Unbundling
Unbundling occurs when a provider bills each component of a procedure separately to receive higher total reimbursement instead of using the single comprehensive code that covers all components.
Question 3: A 'qui tam' lawsuit filed under the False Claims Act allows:
- The government to sue healthcare providers directly without evidence
- Private citizens to file suit on behalf of the government and share in any financial recovery (Correct answer)
- Patients to sue for medical malpractice in federal court
- Insurance companies to recover overpayments from providers
Correct answer: Private citizens to file suit on behalf of the government and share in any financial recovery
The qui tam provision allows private individuals (relators) to file suit on behalf of the government against those who defraud federal programs and receive a percentage of any recovery.
Question 4: Recovery Audit Contractors (RACs) are primarily designed to:
- Approve prior authorization requests before services are rendered
- Identify and recover improper Medicare and Medicaid payments after they have been made (Correct answer)
- License healthcare providers to participate in Medicare
- Process Medicare claims for timely payment to providers
Correct answer: Identify and recover improper Medicare and Medicaid payments after they have been made
RACs identify and recover improper payments—both overpayments and underpayments—in Medicare and Medicaid programs through post-payment audits of provider claims.
Question 5: A provider submits the same claim to Medicare twice for a single patient visit that occurred only once. This is an example of:
- Upcoding
- Unbundling
- Churning
- Double billing (Correct answer)
Correct answer: Double billing
Double billing (duplicate billing) involves submitting the same claim more than once for a service performed only once, resulting in improper duplicate payment.
Question 6: 'Churning' in the context of healthcare fraud refers to:
- Submitting claims for services performed by unlicensed staff
- Performing medically unnecessary repeat procedures or visits primarily to generate additional billing (Correct answer)
- Billing for services provided by a different provider than the one listed on the claim
- Using incorrect diagnosis codes to justify additional procedures
Correct answer: Performing medically unnecessary repeat procedures or visits primarily to generate additional billing
Churning involves scheduling patients for unnecessary repeat visits or procedures primarily to generate additional insurance billing rather than for legitimate medical reasons.
Question 7: When a healthcare organization identifies that it has received a Medicare overpayment, it must report and return the overpayment within:
- 30 days of identification
- 60 days of identification (Correct answer)
- 90 days of identification
- 180 days of identification
Correct answer: 60 days of identification
The Affordable Care Act requires that identified Medicare and Medicaid overpayments be reported and returned within 60 days; failure to do so can result in False Claims Act liability.
NCICS Healthcare Fraud, Waste & Abuse Prevention 2
The Anti-Kickback Statute (AKS) prohibits which of the following activities?