CHC - Certified in Healthcare Compliance Healthcare Fraud and Abuse Questions and Answers

Question 1

A hospital provides a physician with free office space in a medical office building it owns. The physician, in turn, refers a significant number of Medicare patients to the hospital for various services. This arrangement is not structured to fit within any safe harbor. Which of the following federal laws is most likely implicated by this arrangement?

Accepted Answer

The Anti-Kickback Statute (AKS)

Answer

The Anti-Kickback Statute (AKS) is a criminal law that prohibits the knowing and willful exchange of anything of value (remuneration) to induce or reward referrals for items or services payable by federal healthcare programs. The free office space is considered remuneration, and its provision in exchange for patient referrals directly implicates the AKS. While violations could lead to CMPL penalties, the core issue described is a potential kickback.

Question 2

A key distinction between the Stark Law and the Anti-Kickback Statute (AKS) is that the Stark Law:

Accepted Answer

applies only to referrals made by physicians for designated health services (DHS).

Answer

The Stark Law is more narrowly focused than the AKS. It specifically prohibits physicians from referring Medicare or Medicaid patients for 'designated health services' to entities with which they (or an immediate family member) have a financial relationship, unless an exception applies. The AKS applies more broadly to any remuneration for referrals of any federal healthcare business and is not limited to physicians or DHS.

Question 3

An employee in a hospital's billing department discovers a systematic software error that has caused the hospital to 'upcode' claims for a specific outpatient procedure for the past two years, resulting in significant overpayments from Medicare. Under the False Claims Act (FCA), what is the employee's best course of action to report this and potentially receive a percentage of the recovery?

Accepted Answer

File a 'qui tam' lawsuit on behalf of the government.

Answer

The False Claims Act includes 'qui tam' provisions that allow a private individual, known as a relator, to file a lawsuit on behalf of the United States government. If the lawsuit is successful, the relator is entitled to a percentage of the funds recovered. This is the formal mechanism for a whistleblower to report fraud and be eligible for a reward under the FCA.

Question 4

The Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in federal healthcare programs. Which of the following would trigger a MANDATORY exclusion?

Accepted Answer

A felony conviction for patient abuse or neglect.

Answer

The OIG is required by law to exclude individuals and entities convicted of certain criminal offenses. These mandatory exclusions include felony convictions for Medicare or Medicaid fraud, patient abuse or neglect, and other healthcare-related felonies. The other options listed are grounds for a permissive exclusion, where the OIG has discretion.

Question 5

A diagnostic imaging center owned by a group of physicians refers its Medicare patients exclusively to an affiliated physical therapy practice in which the same physicians also hold an ownership interest. To comply with the Stark Law, this financial relationship must:

Accepted Answer

fit squarely within a designated statutory or regulatory exception.

Answer

The Stark Law prohibits physician self-referrals for designated health services (like physical therapy) to entities where they have a financial interest. The law is a strict liability statute, meaning intent is not a factor. For the arrangement to be permissible, it must satisfy all requirements of a specific exception, such as the in-office ancillary services exception.

CHC - Certified in Healthcare Compliance Practice Test

CHC - Certified in Healthcare Compliance Practice Test

CHC - Certified in Healthcare Compliance Healthcare Fraud and Abuse Questions and Answers