Fraud and Abuse

Question 1

What is a mistake or error for medicare?

Answer 1

incorrect coding

Question 2

What are inefficiencies or waste according to medicare?

Answer 2

providing medically unnecessary service

Question 3

What is bending the rules or abuse according to medicare?

Answer 3

improper billing practice like upcoding

Question 4

What is intentional deception of fraud according to medicare?

Answer 4

billing for services that were not provided

Question 5

What is the medicare anti-kickback statute?

Answer 5

knowingly, indirectly or directly, paying for referrals

Question 6

Who is responsible for kickback?

Answer 6

both parties involved

Question 7

What are the penalties for kickback?

Answer 7

up $25,000 and or 5 years in prison; exclusion from medicare

Question 8

What are safe harbors?

Answer 8

renting a space you own out to someone for a decreased rate for referrals (have to put at a fair market value)

Question 9

What should one always do when operating with safe harbors?

Answer 9

arms length contract or agreement (written); fair market value

Question 10

What should we know in relation to Medicare Billing?

Answer 10

all rules and regs applicable to services billed by the provider and or on behalf of the provider.

Question 11

What can result from falsification of Medicare billing?

Answer 11

can be punished by criminal, civil, or administrative penalties or imprisonment

Question 12

What is the civil false claims act?

Answer 12

the statue under which medicare/medicaid fraud is prosecuted.

Question 13

What are the required elements for submission under the civil false claims act?

Answer 13

1. submission of a claim for payment to medicare
2. claim that was false or fraudulent
3. clamant acted knowingly

Question 14

What are possible penalties for false claims?

Answer 14

fines and jail time

Question 15

What are Qui Tam Actions?

Answer 15

whistleblower lawsuits where employees report employers. (blower can potentially collect if case goes through)

Question 16

What are corporate compliance programs?

Answer 16

internal programs that help an organization avoid fraud and monitor for safety of the organization over the individual

Question 17

Where must profits of a NFP organization go?

Answer 17

back into the organization

Question 18

Can a physician own a PT or OT clinic?

Answer 18

yes, as long as it is within their clinic and bills services as their own; services must still be provided by the proper professional

Question 19

Can a PTA work directly for a physician?

Answer 19

no, must work under a licensed PT

Question 20

What is malfeasance?

Answer 20

doing something stupid that one is not supposed to do (practice outside of practice act)

Question 21

What is misfeasance?

Answer 21

doing something stupid (US on the temple)

Question 22

What is nonfeasance?

Answer 22

should have taken action but did not (did not refer to ER when necessary

Question 23

Ordinary vs. gross neglicence?

Answer 23

Ordinary: a reasonable man would have known
Gross: intentional or reckless omission

Question 24

What is required to prove negligence?

Answer 24

1. Duty of Care (legal obligation for care and performance
2. breach of duty of care
3. Injury (loss of income or reputation; pain/suffering/ medical expenses)
4. Causation/Proximate Cause (plaintiff must prove it)

Question 25

What is the difference in burden of proof between civil and criminal trials?

Answer 25

civil is more likely that not while a criminal trial requires beyond a reasonable doubt?

Question 26

Why is there a difference in proof requirements for civial and criminal trials

Answer 26

civil trials result in money while criminal take away life and liberty

Question 27

What is strict liability?

Answer 27

hold seller liable for any and all defective or hazardous products or services regardless of fault

Question 28

What did the Civil Rights Act of 1964 do?

Answer 28

made it illegal for an employer to deny anyone a job due to (race, color, religion sex, or nationality)

Question 29

What did the Age Discrimination in Employment Act of 1967 do?

Answer 29

prohibit age discrimination for individuals over 40

Question 30

What did the equal pay act of 1963 do?

Answer 30

prevents sex based wage discrimination for same job

Question 31

What did the ADA do?

Answer 31

prohibit employment discrimination due to a disability

Question 32

What does the Family and Medical Leave Act cover?

Answer 32

12 weeks unpaid leave for newborn; adoption; dying relative; health condition

Question 33

What are the qualification for the FMLA?

Answer 33

1 year employment for the organization

worked 1250 hours

Question 34

What is the fair labor standards act?

Answer 34

estabilished a minimum wage (currently 7.25) and overtime of 1.5x wage

Question 35

Who is exempted from FLSA?

Answer 35

salaried workers

Question 36

What does FLSA not require?

Answer 36

vacation pay; holiday pay; severance; sick pay; rest periods; premium weekend pay; pay raise;