Healthcare Compliance Flashcards
What is healthcare compliance?
The formal name given to proactive tasks to prevent fraud, waste, or abuse within a healthcare entity
Covers individuals without regard to income or medical history
The foundation of today’s healthcare compliance enforcement policies is the United States Sentencing Commission Guidelines Manual (1991)
What are some myths about compliance?
We are to small to get caught
They won’t bother a small private practice
They only go after physicians
That only happens in New York or LA
They only pursue if a patient gets hurt
We don’t take Medicare so we don’t have to worry
We’ve done it this way for years so they won’t bother us now
How much does the national healthcare anti-fraud association costs the nation annually?
Health care fraud costs the nation about $300 billion annually (about 8 percent of the nations healthcare spending)
What is the most common type of fraud?
Billing for health care services that never were rendered
Either by adding to otherwise legitimate claims charges for services never performed, or by using genuine patient names and health insurance information as the basis for fabricating claims
What is the second most common form of fraud?
Upcoding
Billing for a more costly service or procedure than was actually performed
What is the third most common form of fraud?
Deliberate provision of medically unnecessary services
Unnecessary tests, surgeries, and other procedures
What are the major federal laws affecting business and payment practices in the healthcare field?
The illegal remuneration provisions of the Medicare-Medicaid Anti-Fraud and Abuse Amendments, often referred to as the “Anti-kickback Statute”
The Physician Self-Referral Prohibition statutes known as Stark I & II
The Civil False Claims Act and the Criminal Healthcare Fraud Statute
The Patient Protection and Affordable Care Act
What are civil cases?
Preponderance of evidence
Simply means that in the case, one side is more right in their claims than the other
What are criminal cases?
Beyond a reasonable doubt
What is the anti-kickback statute?
A violation occurs whenever an individual or entity knowingly and will fully offers to pay or solicits any remuneration (including any kick-back, bribe or rebate) directly or indirectly, in cash or in kind, in return for referring a patient or arranging for items or services for which payment may be made under Medicare or Medicaid
What is Omnibus Budget Reconciliation Act of 1993 (“Stark II”)?
Expanded Stark I’s laboratory referral prohibition to include a number of “designated health services” and Medicaid services
Added physical and occupation therapy, radiology, durable medical equipment, parenteral/enteral and prosthetic items, home health services, outpatient prescription drugs and hospital services
*Intends to impede self-referral
Audiologists are not on this list, but they could be added
What are some examples of designated health services?
Clinical Laboratory services
Physical Therapy and Occupational services
Radiology services
Radiation therapy services
Equipment and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services
What is the criminal healthcare fraud statute?
Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of any healthcare benefit program
What is the civil false claims act?
Act most frequently used to pursue clinicians
Prohibits:
Billing for services or items that the provider knows were not actually provided as claimed
The use of an improper billing code which the provider knows will result in greater reimbursement than the proper code
Submitting claims that the provider knows are false
Billing for services represented as being performed by a licensed professional when the services were actually performed by a non-licensed person
Billing for items or services furnished by individuals who have been excluded from participation in federally-funded programs;
Billing for procedures which the provider knows were not medically necessary
What is the meaning of “knowing” under the civil false claims act?
A person has actual knowledge of the information
A person acts in deliberate ignorance of the truth or falsity of the information
A person acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required
What is the patient protection and affordable care act compliance mandate?
Section 6401 of the ACA
Mandates that providers put a compliance plan in place, but an enforcement date had not been issued for that requirement
What are the mandatory reasons for the inspector general’s exclusion authority?
Conviction of “program related” crime
Conviction of patient abuse and neglect
Felony conviction of health care fraud
Felony conviction relating to controlled substances
*minimum 5 years but may be indefinite in length
Must apply for and be granted reinstatement
What are the permissive reasons for the inspector general’s exclusion authority?
Certain misdemeanor convictions
Loss of state license to practice
Failure to repay health education loans
Failure to provide quality care
What fines can violations of the anti-kickback statute result in?
May result in criminal prosecution, including fines of up to $250,000 and imprisonment for up to five years for each violation
What are the civil money penalties?
Up to $50,000 for each violation may also be imposed, as well as damages of up to three times the value of the benefit offered or received in violation of the statute
In addition, HHS might seek to exclude violators from federally funded programs
What are the penalties for the stark legislation?
The loss of federally funded payments, civil fines up to $15,000 for each violation, a civil fine up to $100,000 for each arrangement which a person or entity knows had a principal purpose of assuring referrals that would violate the statute if directly made, a civil fine up to $10,000 for failing to report required information regarding ownership interests to federal programs, refunds to individuals and possible exclusion by HHS from federally funded programs
What are the penalties for violations of the civil false claims act?
May result in fines of up to $10,000 for each false claim, treble damages, and possible suspension from federally-funded health programs
What are the objectives of the healthcare fraud and abuse program?
Punish Wrongdoing
Deter others from committing fraud and abuse
Protect patients against abuse and neglect
Protect integrity of Medicare trust fund and other federal health care programs
Educate patients and providers about the need to prevent health care fraud and to promote compliance
Are citizens incentivized to report fraudulent activity?
Yes
Why did the DHHS develop guidelines?
Fraudulent activity represents a significant drain on our national healthcare resources
Most payments found to be improper were the result of poor documentation or improper coding that could be avoided procedurally
Physicians groups have sought guidance to better protect their practices from the potential for fraudulent or erroneous conduct
*Given by the office of the inspector general for all providers and services (in every setting)
Why should we implement policies based on these guidelines?
To avoid potential liability arising from noncompliance and reduced exposure to penalties
Potential improvements in patient management leading to optimal outcomes
Reduction in denial of claims
What are the seven elements of any compliance program/guideline?
Written policies and procedures (no ruling that you need a program, but it is in your best interest to have one)
A designated compliance officer
Conducting comprehensive training
Internal monitoring and auditing (monitoring is an everyday part of how we conduct business (quality assurance), auditing is episodic and can assist with ongoing quality improvement) - need to demonstrate that you do both
Maintaining clear lines of communication internally (people need to be able to speak up when they see something)
Enforcing disciplinary standards (if you have a rule, you need to enforce it)
Responding to detected violations
What are the possible areas of risk for compliance?
Documentation (the biggest risk)
Billing
Gifts from suppliers
Rental Agreements with other healthcare organizations
Referral arrangements (don’t want anything to look like an arrangement)
What is the first step to creating a compliance program?
Audit yourself to see how things are currently running
What are the requirements for a compliance program?
Reasonably designed, implemented, and enforced
Need to put a legitimate effort forward to address areas of risk
Used to detect criminal, civil, and administrative violations that include standards and procedures to be followed by the organization’s employees and other agents
What are the auditors for medicare/medicaid?
Target probe and education audit
Medicare comprehensive error rate testing
Medicare recovery audit contractors (detect improper payments to providers and are paid a contingency fee)
Medicaid integrity contractor
What are some audit triggers?
Repetition of codes
Unusual code pairings
Gifts from suppliers
Nursing home patients
Frequent special testing
Unbundled codes
Enticements
Is fraud intentional deception?
Yes
Submitting an intentionally fraudulent claim in which the provider has actual knowledge of the falsity of the claim
The provider has a duty to know what the billing staff is doing
The provider is ultimately responsible for claims billed, regardless of who is completing the forms
What are some acts that are medicare fraud?
Billing for services not performed
Misrepresenting the diagnosis to justify payment
Soliciting, offering, or receiving a kickback
Unbundling
Falsifying medical necessity, plans of treatment, or medical records to justify payment
Is abuse different than fraud?
Yes
Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program
Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care
Poor documentation can be abuse
What are some examples of abuse?
Submitting duplicate claims
Upcoding
Maintaining poor documentation
Billing Medicare patients at a higher rate than non-Medicare patients.
Billing for services that do not meet recognized standard of care
Billing for services that do not meet medical necessity threshold
What is medical necessity?
Provided for the diagnosis, direct care and treatment of the patient’s medical condition
Meets the standard of good health practice (for defined diagnostic purpose: not annuals)
Is not for the convenience of the patient or health care practitioner
What are the two types of audits?
Letter
Field
When can audits occur?
Scheduled
Random
Patient complaint
Coding outliers (based on statistical analysis)
What is MACRA?
Medicare Access and CHIP Reauthorization Act of 2015
Changed the way Medicare reimbursed clinicians for value over volume
Shifting away from fee for service
Comes down to defining what a good outcome is
