Laws

Question 1

What entities does HIPAA apply to?

Answer 1

Health plans
Health care clearinghouses
Health care providers

Question 2

What information does HIPAA protect?

Answer 2

Protected Health Information or Individually Identifiable Health Information

Question 3

What is “individually identifiable health information” under HIPAA?

Answer 3

Information, including demographic information, that is created or received by a Covered Entity and relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for health care; and that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify an individual

Question 4

Who is responsible for investigating HIPAA complaints?

Answer 4

The Secretary of the Department of Health and Human Services

and the Office for Civil Rights

Question 5

What are the penalties for HIPAA violations?

Answer 5

(1) C.E. Did Not Know: $100-$50,000
(2) Violation due to reasonable cause, not willful neglect: $1000-$50K
(3) Violation due to willful neglect and timely corrected: $10,000-$50K
(4) Willful neglect, not corrected: $50,000
Calendar year maximum for violations of same provision: $1.5M

Question 6

What is a HIPAA “breach”

Answer 6

A breach is the acquisition, access, use or disclosure of PHI in a manner not permitted under HIPAA that compromises the security or privacy of the PHI. All unallowed acquisition, access, use or disclosures are presumed to be a breach unless the C.E. can demonstrate there is a low probability that the PHI has been compromised based on a risk assessment of 4 factors:

1. nature and extent of PHI
2. unauthorized person who received the PHI
3. whether the PHI was actually acquired or viewed
4. the extent to which the risk was mitigated

Question 7

What does the Anti-Kickback law prohibit?

Answer 7

Asking for or receiving anything of value for referral of business to a government funded health care program.
For example, offering bribes or rebates

Question 8

What are the penalties for Anti-Kickback violations?

Answer 8

Criminal penalties: Felony. $25K per violation and up to 5 years in prison
Civil penalties under False Claims Act: Up to 3x the loss plus $11,000 per claim
Civil Monetary Penalty: $50K per violation and up to 3x value of kickback

Question 9

What does the Stark law prohibit?

Answer 9

Improper referrals to entity with which you have a financial relationship

Question 10

What is another term for the Stark law?

Answer 10

Phsyician self-referral law

Question 11

What are the penalties for a Stark/Physician self-referral violation?

Answer 11

Owe back amount of claim
Civil penalties under False Claims Act: Up to 3x the loss plus $11,000 per claim
Civil Monetary Penalty: $15K per service/$100K per scheme
Exclusion from federal health programs

Question 12

How do you determine if there is a Stark/Physician self-referral violation?

Answer 12

1) is there a referral from a physician for a health service
2) does physician have a financial relationship with the entity that received the referral (e.g. an ownership interest)
3) does relationship fit into an exception? (e.g. employment, space and equipment lease)

Question 13

What are 2 main differences between Stark and Anti-kickback?

Answer 13

1) Stark has civil liability only whereas Anti-Kickback has both civil and criminal liability
2) Stark applies only to physicians whereas Anti-Kickback applies to physicians and other providers

Question 14

What governmental agencies enforce Stark, Anti-Kickback and False Claims Act?

Answer 14

Office of Inspector General (OIG)

US Department of Justice

Question 15

What are the two types of exclusion authorities that the OIG has?

Answer 15

Mandatory: Conviction of program related crime; felonies for controlled substances
Permissive: failure to repay school loans, etc.

Question 16

How long does an OIG exclusion last?

Answer 16

Minimum of 5 years, indefinite for exclusions based on license actions, etc. Must apply for reinstatement.

Question 17

What are some different types of health care fraud that could be the basis of a False Claim Act lawsuit?

Answer 17

Services Not Rendered/Add-on Services
Upcoding and Unbundling
Kick-backs
False Certification and Information
Lack of Medical Necessity
Fraudulent Cost Reports
Grant or Program Fraud

Question 18

What are the penalties for an individual or organization found guilty of violating the False Claims Act?

Answer 18

Up to three times the loss, penalty of $5,500 to $11,000 per violation

Question 19

What constitutes a violation of the False Claim Act?

Answer 19

Any person who knowingly presents, or causes to be presented, to the U.S. Government a false or fraudulent claim for payment or approval of a government payment; knowingly makes, uses, or cause to be made or used a false record or statement to get a false or fraudulent claim allowed or paid violates the False Claim Act. Must be material.

Knowing or Knowingly is defined as:

1) has actual knowledge of the information
2) acts in deliberate ignorance of the truth or falsity of the information
3) acts in reckless disregard of the truth or falsity of the information