Chapter 10 - Organizational Compliance And Risk

Question 1

Abuse

Answer 1

Practices that directly or indirectly result in unnecessary costs to the Medicare program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced

Question 2

Anti-Kickback Statute (AKS)

Answer 2

Statute that makes knowingly offering, paying, soliciting, or receiving any remuneration that rewards referrals for services reimbursable by a Federal program a criminal offense

Question 3

Centers for Medicare and Medicaid Services (CMS)

Answer 3

The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Historically, CMS has maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for the oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set

Question 4

Civil Monetary Penalties Law

Answer 4

Authorizes the imposition of substantial civil money penalties against an entity that engages in activities including, but not limited to 1.knowingly presenting or causing to be presented a claim for services not provided as claimed or which is otherwise false or fraudulent in any way; 2.knowingly giving or causing to be given false or misleading information reasonably expected to influence the decision to discharge a patient; 3. offering or giving remuneration to any beneficiary of federal health program likely to influence the receipt of reimbursables items or services; 4. arranging for reimbursables services with an entity which is excluded from participation from a federal health care programs; 5. knowingly or willfully solicitating or receiving remuneration for a referral of a federal health care program beneficiary; or 6. using a payment intended for a federal health care program beneficiary for another use

Question 5

Contingency planning

Answer 5

A comprehensive plan that highlights potential vulnerabilities and threats as well as to identify the approaches to either prevent them or at least minimize the impact; there are three major categories or types of threats: natural threats (floods, earthquakes); technical or man-made (mechanical, biological); Intentional acts (terrorism, computer security

Question 6

Corporate integrity agreement (CIA)

Answer 6

A compliance program imposed by the government, which involves substantial government oversight and outside expert involvement in the organization’s compliance activities and is generally required as a condition of settling a fraud and abuse investigation

Question 7

Emergency Medical Treatment and Active Labor Act (EMTALA)

Answer 7

A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat “patient dumping” –the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)

Question 8

Exclusion Provisions

Answer 8

A component of the Social Security Act that indicates that the Office of Inspector General has the authority to exclude individuals from participating in federal health care programs and will not pay for items or services furnished by an excluded individual or entity

Question 9

False Claims Act (FCA)

Answer 9

Legislation passed during the civil war, amended in 1986, that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse (Public Law 99-562 1986)

Question 10

Fraud

Answer 10

The intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s)

Question 11

Healthcare Fraud Statute

Answer 11

Identifies that it is illegal to defraud any healthcare benefit program or to obtain fraudulent funds or property by any of the healthcare benefit programs

Question 12

Identity Theft

Answer 12

A fraud attempted or committed using identifying information of another person without authority

Question 13

Medical identity thef

Answer 13

The inappropriate or unauthorized misrepresentation of another’s identity to do one of two things: obtain medical services or goods, or falsify claims for medical services in an attempt to obtain money

Question 14

Office of the Inspector General (OIG)

Answer 14

Mandated by Public Law 95-452 (as amended) to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs. The OIG has a responsibility to report both to the Secretary and to the Congress program and management problems in recommendations to correct them. The OIG’s duties are carried out through a nationwide network of audits, investigations, inspections, and other mission-related functions performed by OIG components

Question 15

OIG workplan

Answer 15

Yearly plan released by the OIG that outlines the focus for reviews and investigations in various healthcare settings

Question 16

Potentially compensable event (PCE)

Answer 16

An event (for example, an injury, accident, or medical error) that may result in financial liability for health care organization, for example, an injury, accident, or medical error

Question 17

Red Flags Rule

Answer 17

Requires many businesses and organizations to implement a written identity theft prevention program designed to detect the “red flags” of identity theft in day-to-day operations, takes steps to prevent the crime, and mitigate its damage

Question 18

Risk management

Answer 18

A comprehensive program of activities intended to minimize the potential for injuries to occur in a facility and to anticipate and respond to ensuring liabilities for those injuries that do occur. The processes in place to identify, evaluate, and control risk, defined as the organization’s risk of accidental financial liability

Question 19

Stark Law

Answer 19

Law that prohibits a physician from referring certain health services to an entity in which the physician (or member of immediate family) has an ownership or investment or with which the physician has a compensation arrangement, unless an exception applies

Question 20

Waste

Answer 20

To encompass overutilization, underutilization, or misuse of resources; anything that does not add value to a product or service from the standpoint of the customer

Question 21

Whistleblowers

Answer 21

Individuals, including employees, patients, and competitors who bring lawsuits based on their knowledge of fraud