Chapter 13. Cost, Ethics, and Medicolegal Aspects in Pain Medicine Flashcards
1
Q
- What are the penalties under the False Claims
Act?
(1) Three times the amount of damages suffered
by the government
(2) Amandatory civil penalty of at least $5500
and no more than $11,000 per claim
(3) Submit 50 false claims for $50 each (liability
between $282,500 and $557,500 in damages)
(4) Program exclusion
A
- (E) Penalties under False Claims Act:
• Three times the amount of damages suffered
by the government.
• A mandatory civil penalty of at least $5500
and no more than $11,000 per claim.
• Submit 50 false claims for $50 each (liability
between $282,500 and $557,500 in damages).
• Program exclusion.
2
Q
- What are the steps to compliance of security
standards for electronic patient records?
(1) Administrative safeguards
(2) Physical safeguard
(3) Technical safeguard
(4) Financial viability safeguard
A
- (A) The new rule on the security of electronic
patient records boils down to three sets of standards
that practices will need to implement
step-by-step. - In the area of administrative safeguards we
have the following:
• Assess computer systems.
• Train staff on procedures.
• Prepare for aftermath of hackers or catastrophic
events.
• Develop contracts for business associates. - In the area of physical safeguard we have
the following:
• Set procedures for workstation use and
security.
• Set procedures for electronic media reuse
and disposal. - In the area of technical safeguard we have
the following:
• Control staff computer log-in and log-out.
• Monitor access of patient information.
• Set up computers to authenticate users. - There is no financial viability safeguard.
3
Q
- Identify all accurate statements:
(1) The Emergency Medical Treatment and
Active Labor Act (EMTALA) only applied
to patients who are physically in a hospital’s
emergency department
(2) Physicians in a group practice may receive
productivity bonuses without violating
the Stark Self-Referral Rules if the bonuses
are based on a physician’s total number of
patient encounters or relative value units
(RVUs)
(3) You purchase a medical practice that is
currently subject to a corporate integrity
agreement (CIA), and the transfer of ownership
will void the CIA
(4) According to the Department of Health
and Human Services Office of Inspector
General (OIG), having a compliance program
without appropriate, ongoing
monitoring is worse than not having a
compliance program
A
- (C)
- EMTALA, also known as the patient
antidumping law applies to an individual
who requests examination or treatment and
who is on hospital property (including offcampus
clinics and hospital-owned ambulances
that are not on hospital grounds). An
individual in a non–hospital-owned ambulance
on hospital property is also considered
to have come to the hospital’s emergency
department. - Profit shares and productivity bonuses are
permitted if they meet certain conditions.
Physicians in a group practice, including independent
contractors, may get shares of “overall
profits” of the group or receive bonuses for
services they personally perform—including
incident-to-services—if such rewards are not
based on referrals for any of the designated
health services.
Regardless of which type of reward is
given, documentation that verifies how
much was given and on what basis must be
made available to investigators if requested.
Overall profits are the profits from designated
health services for the entire group or
any part of the group that has at least five
physicians. The profits are not based on
referrals if only one of the following conditions
is met:
• The profits are divided per capita (per
member or per physician, for example).
• Designated health services revenue is distributed
based on the way nondesignated
health services revenue is distributed.
• Designated health service revenue is both
less than 5% of the group’s total income
and is less than 5% of any physician’s
total compensation from the group.
• Overall profits are distributed in a reasonable
and verifiable way that is unrelated
to designated health service referrals.
Productivity bonuses are not based on
referrals if
• It is based on a physician’s total number
of patient encounters or RVUs.
• It is not based in any way on designated
health services.
• Designated health service revenue is both
less than 5% of the group’s total income
and is less than 5% of any physician’s
total compensation from the group.
• It is distributed in a reasonable and verifiable
way unrelated to designated health
services DHS referrals. - and 4. Corporate integrity agreements
(CIAs) are typically large, detailed and
restrictive compliance plans that companies
enter into as part of a deal with the
Department of Health and Human Services
Office of Inspector General (OIG). CIAs are
intended to make sure that a company never
again commits the kind of offenses against
the Medicare program that landed it in trouble
in the first place. There are strict reporting
requirements and other rules a company
must live up to once it agrees on a plan with
OIG, but on the plus side, OIG allows the
company to continue to do business with
Medicare.
4
Q
- Local medical review policy (LMRP) or local
coverage determination (LCD) is utilized in all
states. Which of the following is (are) true?
(1) LMRP or LCD is developed to assure beneficiary
access to care
(2) Frequent denials indicate a need for development
of LMRP or LCD
(3) A need for development of LMRP or LCD
includes a validated widespread problem
(4) LMRPs or LCDs are the policies used to
make coverage and coding decisions in the
absence of specific statute, regulations,
national coverage policy, and national coding
policy or as an adjunct to a national
coverage policy
A
- (E) LMRPs or LCDs are those policies used to
make coverage and coding decisions in the
absence of the following:
• Specific statute
• Regulations
• National coverage policy
• National coding policy
• As an adjunct to a national coverage policy
Development of LMRP—identification of
need
• A validated widespread problem.
• Identified or potentially high dollar
and/or high volume services.
• To assure beneficiary access to care.
• LMRP development across its multiple
jurisdictions by a single carrier.
• Frequent denials are issued or anticipated.
LMRP’s reduce utilization and save money.
5
Q
- True statements about qui tam (Whistleblower
Act) are as follows:
(1) Suits are usually brought by employees
(2) If the government proceeds with the suit,
the whistleblower receives 50% to 60% of
settlement
(3) Individuals can bring suit against violators
of federal laws on their own behalf as
well as the government’s
(4) If the government does not proceed and
the individual continues, the individual
receives 100% of the settlement
A
- (B)
6
Q
- Identify true statement(s) differentiating consultation
and referral visit:
(1) Written request for opinion or advice
received from attending physician, including
the specific reason the consultation is
requested
(2) Patient appointment made for the purpose
of providing treatment or management
or other diagnostic or therapeutic
services
(3) Only opinion or advice is sought. Subsequent
to the opinion, treatment may be initiated
in the same encounter if criteria are
fulfilled
(4) Transfer of total patient care for management
of the specified condition
A
- (B) Consultation versus referral visit (see Table
below)
7
Q
- What are some of the important aspects of documentation
of medical necessity?
(1) Medicare will reimburse irrespective of
the procedure, furnished, not for improvement
function, but 20% pain relief
(2) The physician practice should be able to
provide documentation such as a patient’s
medical records and physician’s orders, to
support the appropriateness of a service
that the physician has provided
(3) Medicare concurs with physician opinion
and patient request with respect to duration,
frequency, and setting a procedure performed
(4) The physician practice should only bill
those services that meet the Medicare standard
of being reasonable and necessary for
the diagnosis and treatment of a patient
A
- (C)
Reasonable and necessary service must be
• Safe and effective.
• Not experimental or investigational.
• Appropriate, including the duration and
frequency that is considered appropriate
for the service, in terms of whether it is
• Furnished in accordance with accepted
standards of medical practice for the diagnosis
or treatment of the patient’s condition
or to improve the function.
• Furnished in a setting appropriate to the
patient’s medical needs and condition.
• Ordered and/or furnished by qualified
personnel.
• One that meets, but does not exceed, the
patient’s medical need.
Documenting medical necessity
• The physician practice should be able to
provide documentation such as a patient’s
medical records and physician’s orders, to
support the appropriateness of a service
that the physician has provided.
• Only bill those services that meet the
Medicare standard of being reasonable and
necessary for the diagnosis and treatment of
a patient.
8
Q
- What is (are) the correct statement(s) about a
deficient (dated) practitioner?
(1) Too busy to keep up with CME
(2) Only aware of a few treatments or medications
(3) Prescribes for friends or family without a
patient record
(4) Well aware of controlled-drug categories
A
- (E) The following are correct statements about
a deficient (dated) practitioner:
• Too busy to keep up with CME.
• Unaware of controlled-drug categories.
• Only aware of a few treatments or medications.
• Prescribes for friends or family without a
patient record.
• Unaware of symptoms of addiction.
• Remains isolated with peers.
• Only education from reps.
9
Q
- Identify accurate statement(s) about clinical
policies:
(1) They are expensive and labor intensive to
develop and maintain
(2) The actual impact on the quality of care is
nearly impossible to determine
(3) There are probable multiple indirect positive
benefits of this effort with improved patient
care and decreased practice variation
(4) They provide an inordinate amount of
restrictions
A
- (A) The following are correct statements about
clinical policies:
• Expensive and labor intensive to develop
and maintain.
• Actual impact on the quality of care is
nearly impossible to determine.
• Probable indirect positive benefits of this
effort like
Increased acceptance of concept of “standards”.
Increased attention to our individual practices
of medicine, especially over time.
Decreased practice variation.
Pay for performance.
10
Q
- What are the Federation of State Medical
Board’s guidelines for the treatment of pain?
(1) Use of controlled substances, including opiates
may be essential in the treatment of
pain
(2) Effective pain management is a part of
quality medical practice
(3) Patients with a history of substance abuse
may require monitoring, consultation, referral,
and extra documentation
(4) MDs should not fear disciplinary action
for legitimate medical purposes
A
- (E) Federation of State Medical Board’s guidelines
for the treatment of pain include
• Use of controlled substances, including opiates
may be essential in the treatment of pain.
• Effective pain management is a part of
quality medical practice.
• Patients with a history of substance abuse
may require monitoring, consultation,
referral, and extra documentation.
• MDs should not fear disciplinary action for
legitimate medical purposes.
11
Q
- Exclusion means which of the following for a
provider?
(1) A prohibition from providing health care
services for a period of time
(2) A prohibition from billing federal health
programs for items or services
(3) A prohibition from practicing as a physician
for a period of time
(4) A prohibition from receiving reimbursement
from federal health care programs
for items or services
A
- (C) Exclusion means a provider is barred from
receiving reimbursement from Medicare,
Medicaid, or other federal health care programs.
There are two types of exclusion: mandatory
and permissive. Under mandatory exclusion,
HHS must exclude—it has no choice. Under
permissive exclusion, HHS has some discretion.
