Legal Aspects 4-6 Flashcards
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Examples of federal enforcement agencies
DOJ OIG CMS Office of medicare hearings and appeals Department appeals board Office of civil rights Office for national coordinator of health information technology
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Examples of federal enforcement agencies - DOJ
Department of Justice - especially oversight on criminal justice, false claims act
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Examples of federal enforcement agencies - OIG
Office of inspector general - good resource for compliance related info
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Examples of federal enforcement agencies - CMS
Center for medicare and medicaid services
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Examples of federal enforcement agencies - Office of medicare hearings and appeals
Defending a denied claim will lead you to maybe get involved with this
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Examples of federal enforcement agencies - Office for civil rights
Enforcement - HIPAA, non discrimination
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Examples of federal enforcement agencies - Office for national coordinator of health information technology
More relevant in the last couple of years because of standardized communication with health care providers and also use of EMRs
Health care laws - purpose
Protection of the public
Integrity of government health care programs
Establish conditions of participation for providers to follow when participating in government health care programs
Create basis for monetary/criminal penalties
Health care laws and PT practice
A PT must be reasonably familiar with health care laws
- State licensure laws
- Fraud and abuse laws
- HIPAA privacy, security and breach notification laws
Fraud vs. Abuse
Primary difference is intention!
Fraud - when someone intentionally deceives or makes misrepresentations to obtain money or property of any health care benefit program
Abuse - when health care providers or suppliers perform actions that directly or indirectly result in unnecessary costs to any health care benefit program
Common fraud and abuse in PT
Billing for more minutes of therapy than is actually provided
Billing for services that were never rendered
Upcoding
Unbundling
Failure to maintain documentation to support medical necessity
Ramping up - to achieve higher reimbursement category then immediately dropping services down
Federal false claims act
FCA - dates back to civil war
Intent is to deter bad actors from submitting bad claims to federal government
Federal false claims act - liability for certain acts - in general - any person who
1 knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval
2 knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim
Don’t submit claims to the government that there is no support for
State false claims act - a person who commits any of the following
Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval
Knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim
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Fraud and abuse - APTA code of ethics- Principle 4
PTs shall demonstrate integrity in their relationships with pts/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public
PTs shall provide truthful, accurate, and relevant information and shall not make misleading representations
Fraud and abuse - PT licensure - the board may impose any disciplinary sanctions when board determines that the license is guilty of:
Knowingly making misleading, deceptive, untrue or fraudulent representations in the practice of PT or engaging in unethical conduct or practice harmful or detrimental to the public
Proof of actual injury need not be established
Duties of licensees -
A licensee has a continuing duty to report to the licensing board by whom the person is licensed those acts or omission specified by rule of the board when committed b another person licensed by the same licensing board
A license who willfully fails to comply commits a violation of this chapter for which licensee discipline may be imposed
Duties of licensees - Grounds for discipline
The board my impose any of the disciplinary sanctions provided
Failure to report another licensee to the board for any violations listed in the rules
False claims act and overpayments - Two laws amended the federal false claims act to address and clarify reporting and repaying “overpayments”
Fraud enforcement and recovery act of 2009 (FERA) - Reverse false claim
Pt protection and affordable care act (ACA) - time date (60 days) once you identify an overpayment to get it paid back
Key aspects of FERA and PPACA - FERA of 2009
Amends FCA
Broadens liability to require repayment of overpayment
Reverse false claim
Easier to prosecute and to bring whistleblower claim
Program exclusion applies
Key aspects of FERA and PPACA - ACA of 2010
Amends SSA
Requires repayment within 60 days of identification
Links retention of overpayments to FCA
Additional money penalty for failure to report
Overpayment - defined
Any funds that a person receives or retains to which the person, after applicable reconciliation is not entitled
Examples of overpayment - could include
Medicare payments for non covered services
Medicare payments in excess of the allowable amount for an identified covered service
Errors and non reimburseable expenditure in cost reports
Duplicate payments
Receipt of medicare payment when another payer had the primary responsibility for payment
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Reverse false claim is what
When providers knowingly retain medicare or medicaid overpayments they are not entitled to
Extends FCA liability to the retention of overpayments received, whether you specifically intended to receive them or not
Once you identify you’ve been overpaid by the gov, you have an obligation to repay the overpayment back
How can a PT create a reverse false claim? When he/she discovers what
A failure to maintain supporting documentation of services
Duplicate billing for services
Clear billing errors
Payment for services that were never rendered
Payments stemming from kick backs or stark violations
Once you identify you’ve been pain beyond what you should, you have a duty to report and repay within 60 days
Current process to report an overpayment
Providers must use applicable claims adjustment, credit balance, self reported refund, or another appropriate process to satisfy the obligation to report and return over payments
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Whistleblower is what
Usually an employee who reports employer illegality to governmental or law enforcement agency
Many laws protect the actions of legitimate whistleblowers
Whistleblowing in PT practice -
False representation of PT services delivered by a PT
Claims submitted to gov for individual tx when group tx provided
PT claims to gov as a result of inc amounts of PT to hit medicare reimbursement targets
Anti kickback and stark laws - what kind of laws are they
These are federal fraud and abuse laws
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Anti kickback and stark laws - what are they
They prohibit the payment to induce referrals that are otherwise paid for in whole or in part by a federal gov health care program such as medicare and medicaid
Anti kickback and stark laws - violation
Violation of anti kickback law or stark law can result in either criminal and/or civil penalties
Anti kickback and stark laws - violation - example
A referring physician cannot receive compensation directly or indirectly based on their referrals for medical services where those services could possible be reimbursed by federal or state health care dollars
Physician is defined as including any immediate family member of physician
OIG exclusion authority
OIG has the authority to exclude individuals and entities from federally funded health care programs pursuant to sections of the social security act
Exclusions are imposed for number of reasons - but all under category of
- mandatory exclusions
- permissive exclusions
Not paying back student loans! Licensure ones can be indefinite! Once period is over - reinstatement is NOT automatic
Effecive compliance programming
FSG
OIG
Federal sentencing guidelines (FSG) - Effective compliance programming is the goal
- Education
- Diligence (credentials)
- Reporting (timely)
- Responsive
- Enforcement
- Establish compliant culture
OIG seven elements of effective compliance program:
- written policy and procedures
- compliance officer
- effective training of workforce
- effective communication (hotline)
- internal monitoring and auditing
- enforce standards
- prompt response to issues
Appeals process - medicare claim denial - Original medicare has 5 levels of appeal
Redetermination Reconsideration Administrative law judge hearing Medicare appeals counsel review Judicial review in federal district court
Appeals process - private health plans
Will vary but here are some common elements
- Explicit time frames for responding
- Most plans have two levels of internal appeal
- Most states allow for 3rd level external appeal
Appeals process - private health plans - try to avoid denial by
Ensuring preauthorization requests include accurate and complete patient demographics as well as the proper diagnosis and procedure codes
Good documenation!!!
NCD vs. LCD
National coverage determinations
Local coverage determinations
These rules specifiy the services that are allowed for certain diagnoses
NCDs are medicares standard, national rules
LCDs are local carriers versions of NCDs
NCD vs. LCF - medicare coverage is limited to items and services that are considered ____ and ____ for the diagnosis or treatment of an illenss or injury
reasonable and necessary
NCDs originate from ____
NCD vs. LCD
CMS and apply to all medicare jurisdictions
NCD decisions are binding on all medicare contractors and LCD policy can be no more restrictive than NCD, although it can be less restrictive
In the absence of NCD
an item or service is covered at the discretion of the medicare contractors based on a LCD
HIPAA
Health insurance portability and accountability act
PHI
Protected health information of indicudal patients
HIPAA - four main rules improtant to health care providers
Privacy rule
Security rule
Breach notification rule
Final omnibus rule
HIPAA trends - DHHS must now
periodically audit covered entities and business associates to assure they are complying with the HIPAA privacy and security rules and breach notification standards
Perfoamnce audits - HIPAA
OCR was charged with establishing and implementing a HIPAA performance audit protocol
