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Block 7 PID Exam 6 > Legal Aspects 4-6 > Flashcards

Legal Aspects 4-6 Flashcards

1
Q

EXAM!!!

Examples of federal enforcement agencies

A 
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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2
Q

EXAM!!!

Examples of federal enforcement agencies - DOJ

A

Department of Justice - especially oversight on criminal justice, false claims act

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3
Q

EXAM!!!

Examples of federal enforcement agencies - OIG

A

Office of inspector general - good resource for compliance related info

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4
Q

EXAM!!!

Examples of federal enforcement agencies - CMS

A

Center for medicare and medicaid services

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5
Q

EXAM!!!

Examples of federal enforcement agencies - Office of medicare hearings and appeals

A

Defending a denied claim will lead you to maybe get involved with this

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6
Q

EXAM!!!

Examples of federal enforcement agencies - Office for civil rights

A

Enforcement - HIPAA, non discrimination

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7
Q

EXAM!!!

Examples of federal enforcement agencies - Office for national coordinator of health information technology

A

More relevant in the last couple of years because of standardized communication with health care providers and also use of EMRs

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8
Q

Health care laws - purpose

A

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

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9
Q

Health care laws and PT practice

A

A PT must be reasonably familiar with health care laws

  • State licensure laws
  • Fraud and abuse laws
  • HIPAA privacy, security and breach notification laws
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10
Q

Fraud vs. Abuse

A

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

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11
Q

Common fraud and abuse in PT

A

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

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12
Q

Federal false claims act

A

FCA - dates back to civil war

Intent is to deter bad actors from submitting bad claims to federal government

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13
Q

Federal false claims act - liability for certain acts - in general - any person who

A

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

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14
Q

State false claims act - a person who commits any of the following

A

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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15
Q

EXAM!!!

Fraud and abuse - APTA code of ethics- Principle 4

A

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

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16
Q

Fraud and abuse - PT licensure - the board may impose any disciplinary sanctions when board determines that the license is guilty of:

A

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

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17
Q

Duties of licensees -

A

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

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18
Q

Duties of licensees - Grounds for discipline

A

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

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19
Q

False claims act and overpayments - Two laws amended the federal false claims act to address and clarify reporting and repaying “overpayments”

A

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

20
Q

Key aspects of FERA and PPACA - FERA of 2009

A

Amends FCA
Broadens liability to require repayment of overpayment
Reverse false claim
Easier to prosecute and to bring whistleblower claim
Program exclusion applies

21
Q

Key aspects of FERA and PPACA - ACA of 2010

A

Amends SSA
Requires repayment within 60 days of identification
Links retention of overpayments to FCA
Additional money penalty for failure to report

22
Q

Overpayment - defined

A

Any funds that a person receives or retains to which the person, after applicable reconciliation is not entitled

23
Q

Examples of overpayment - could include

A

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

24
Q

EXAM!!!

Reverse false claim is what

A

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

25
Q

How can a PT create a reverse false claim? When he/she discovers what

A

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

26
Q

Current process to report an overpayment

A

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

27
Q

EXAM!!!

Whistleblower is what

A

Usually an employee who reports employer illegality to governmental or law enforcement agency
Many laws protect the actions of legitimate whistleblowers

28
Q

Whistleblowing in PT practice -

A

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

29
Q

Anti kickback and stark laws - what kind of laws are they

A

These are federal fraud and abuse laws

30
Q

EXAM!!!?

Anti kickback and stark laws - what are they

A

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

31
Q

Anti kickback and stark laws - violation

A

Violation of anti kickback law or stark law can result in either criminal and/or civil penalties

32
Q

Anti kickback and stark laws - violation - example

A

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

33
Q

OIG exclusion authority

A

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

34
Q

Effecive compliance programming

FSG

OIG

A

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
35
Q

Appeals process - medicare claim denial - Original medicare has 5 levels of appeal

A 
Redetermination
Reconsideration
Administrative law judge hearing
Medicare appeals counsel review
Judicial review in federal district court
36
Q

Appeals process - private health plans

A

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
37
Q

Appeals process - private health plans - try to avoid denial by

A

Ensuring preauthorization requests include accurate and complete patient demographics as well as the proper diagnosis and procedure codes
Good documenation!!!

38
Q

NCD vs. LCD

National coverage determinations
Local coverage determinations

A

These rules specifiy the services that are allowed for certain diagnoses
NCDs are medicares standard, national rules
LCDs are local carriers versions of NCDs

39
Q

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

A

reasonable and necessary

40
Q

NCDs originate from ____

NCD vs. LCD

A

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

41
Q

In the absence of NCD

A

an item or service is covered at the discretion of the medicare contractors based on a LCD

42
Q

HIPAA

A

Health insurance portability and accountability act

43
Q

PHI

A

Protected health information of indicudal patients

44
Q

HIPAA - four main rules improtant to health care providers

A

Privacy rule
Security rule
Breach notification rule
Final omnibus rule

45
Q

HIPAA trends - DHHS must now

A

periodically audit covered entities and business associates to assure they are complying with the HIPAA privacy and security rules and breach notification standards

46
Q

Perfoamnce audits - HIPAA

A

OCR was charged with establishing and implementing a HIPAA performance audit protocol

Block 7 PID Exam 6 (4 decks)

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