Class 2:Fraud and Abuse/Licensing Flashcards
Licensure process assures
that whose who optometric services gets it from qualified well trained Ods
Licensure Laws define
what optometry is, how you get a license to do it, what happends if you do it without a license
Scope of Practice Laws
aka practice acts define what professionals can and can’t do
-may be overlap btwn professionals
What three things do licensure laws do?
- describe what is permitted
- Describe what is prohibited
- Describe limitations on what is permitted
Who admistered the Alabama practice act of optometry
Alabama Board of Optometry; issues advisory opinions, conduct investigations, and hold disciplinary proceedings
How do you get in trouble with the AL Board of Optometry ?
practicing w/out a license, helping someone to practicing w/out license, making false statements in application and renewal license apps, using drugs other than approved, unprofessional conduct
Unprofessional conduct is
behavior placing pt at risk, misleading ads, not releasing patient info to patient, not providing emergency (sight-threatening) care to existing patient.
Unprofessional conduct includes practicing beyond the scope of license and not meeting the minimum testing standards.
TRUE
Anti-Kickback statue is a
federal criminal statute
The anti-kickback statue to aplies to ALL federal healthcare programs.
True, it applies to all not just Medicare and Medicaid
What does the ant-kickback statute say
Anyone who OFFERs, PAYS, SOLICITS OR RECEIVES any remunration (direct or indirect) in cash or in return for REFERRING someone for an item or service for which payment may be made under federal healthcare program
The anti-kickback also applies to referalls in return for purchasing , leasing or ordering (arranging for recommending) any good, facility, service, or item for which payment may be made under federal health care program.
true.
Remuneration means
anything of value tangible or intangible: cash, rent discount, free items or services
Referral means
means referral of a patient or purchasing, leasing, ordering of ANY good, facility, service or any portion of the patients care may be paid in whole or in part by Federal healthcare program
Violating the Antikickback Statute requires
intent to influence referrals, but a violation can occur even where there are legitimate purposes, present as well
Can the Anti-Kickback statute form the bases of civil liability?
Yes, it can form the basis of civil liability. It has criminal penalities including prison.
Can you get in trouble if there was only ONE purpose to obtain money for the referral of services or induce futher referrals?
Yes. The “one purpose test” applies to any of those arranagments. An arrangement with 99% good purposes and 1% bad purpose is a violation.
We took the money but didn’t make the referals is NOT a violation of the anti-kickback.
False. The statute applies not just to consummated kickbacks, but offers and solicitations.
Violations of anti-kickback mean that indviduals and corporations are liable.
TRUE
Criminal Penalities for Anti-Kickback statute
Felony -up to 5 years in prison for each offense, criminal fine of up to 25,000, exclusion from government reimbursement programs
If the person settles in the case of violation of ANTI-K they are sometimes required to
enter into a corporate integrity agreement (CIA).
List the enforcement agencies for the ANTI-K
U.S. Dept of Health & Human Services Office of Inspector General (OIG), U.S. Department of Justice (DOJ), Whitstleblowers, Medicare & Medicaid Fraud Units in local US Attorney’s Offices
Safe harbor regulations insulate certain types of arrangements. What are the safe harbors?
Speciality Referral Arrangement btwn providers, Space Rental, Equipment Rental, Space and Equipment Rental, and Personal Service and Management Contracts
T/F Failure to fit with a safe harbor doesn’t mean there is a violation
True.
Specialty Referral Arrangements Between Providers protects
protects certain arrangments when an individual or entity agrees to refer a patient to another individual or entity for speciality services in return for the part receiving the referral to the patient back at a certain or under certain circumstances
Space Rentals/Equipment Rentals must have (list them) in order to limit opportunity absusive relationships with referrals.
lease written and signed; lease speification of premises, extent of lease, lease term must NOT be less than one year, charges must be consistent with the market value.
Personal Service and Management Contracts are when
medical practitions and providers often have agreements to perform services for each other on a mutually benefical basis
What are some of the AKS Danger Zones?***
provider joint ventures, space & equipment leases, personal service contracts, consulting/research/educational arrangments, ancillary service relationships
The “Bright Line” of Stark is commonly referred to as the
“Stark Law”
Stark law is a
strict liability statute
-intent does not matter
What does the Stark Law cover
referrals by a physician, a provider with whom the physician has a financial relationship for designated services for which Medicare or medicaid make make payment
The Bright Line of Stark applies only to
physicians and immediate (adoptive child, in laws, step parents, spouse of grandparent or grandchild) family members of physicians,applies only when a financial relationship exisits
Referral in the Stark Law means
requesting ordering services or certifying medical necessity (including tests ordered pursant to consult)
The Stark Law referral does not include
personally performed services
Stark law referals does include
“incident to” services
Exceptions to Stark Law-Compensation
physician recruitment, payments by physician, charitable donations by physician, a “set in advance” flat amount of aggregate compensation
Sanctions for Non-Compliance: who is reposnible for imposing claims liability
Center for Medicare and Medicaid Services (“CMS”)
Sanctions for non-compliance: who is responsible for imposing penailites for knowing violations
Office of the Inspector General
** AKS is an
intent based criminal statute
** Stark is an
Strict liability civil statute
*** Non-compliance with an AKS Safe harbor is (violation or not necessarily)
Not necessarilty violation
**non compliance with Stark
is ALWAYS a violation
_____ only applies where a physician referral is involved and ONLY to Medicare and Medicaid
Stark
____ is applies in a broader scope
AKS
Compliance with a Stark exception equals compliance with an AKS safe harbor
False. Compliance with Stark does not necesssarily equal compliance with an AKS but some Stark exceptions are condition upon there being no AKS
