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Healthcare Management > Legal/Fraud/Abuse > Flashcards

Legal/Fraud/Abuse Flashcards

1
Q

Medicare Anti-Kickback Statute

A
  • Short defn: you cannot pay for referrals
  • can’t pay physicians to refer pts to PT (both parties in trouble)
  • “prohibits knowingly and willfully soliciting, receiving, offering, or paying any remuneration directly or indirectly, overtly or covertly, in cash or kind, in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under Medicare or Medicaid”
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2
Q

Safe Harbors (Examples)

A
  • investments interests
  • space rental
  • equipment rental
  • personal services (management contracts)
  • sale of practice
  • referral services
  • warranties
  • discounts
  • employee compensation must be based on local market
  • group purchasing organizations
  • physician recruitment and relocation
  • investment in underserved areas
  • OB/GYN malpractice insurance subsidies in underserved areas
  • investments in group practices and ASCs
  • Cooperative hospital service organizations
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3
Q

Safe Market Defn

A

-can engage in monetary transaction, if you’re careful

For us: space rental, equipment rental, staff

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4
Q

Safe Harbors are not ______

A

-a guarantee of safety

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5
Q

Safe harbors should always have an______

A
  • arm’s length written contract/agreement

- not just a handshake

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6
Q

Safe harbors: should always use ________ when purchasing anything from physician or physician purchases anything from you

A

-fair market value

don’t give them discounts just because, government will think you’re up to something

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7
Q

When billing, pay attention to not only what is billed by the provider but ____

A
  • what is billed on behalf of the provider

- (PTAs, office manager etc)

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8
Q

Examples of Fraud

A
  • bill for services not received
  • bill for equip never provided
  • using another person’s medicare card to get care, equip, supplies
  • bills medicare for home medical equip after it’s been returned
  • company offers medicare drug plan that has not been approved by medicare
  • a company uses false info to mislead beneficiary to join medicare replacement plan
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9
Q

Civil False Claims Act

A

-the statute under which medicare/medicaid fraud is prosecuted

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10
Q

Elements of Civil False Claims Act

A
  • submission of a claim for payment to Medicare
  • claim was false/fraudulent
  • claimant acted knowingly
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11
Q

Civil False Claims Act Prohibits

A
  • using a false record to secure payment for a claim

- conspiring to secure payment for a false claim

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12
Q

Triple Damages

A
  • civil
  • 3 times the amount of damages which the government sustained because of the act of that person
  • potential criminal penalties
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13
Q

Qui Tam Action

A
  • whistleblower action
  • most frequent way Medicare is getting reports of fraud/abuse
  • lawsuit where employee in company reports fraud/abuse
  • if you whistle blow your company and the government wins case, you can get part of the settlement
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14
Q

Corporate Compliance Programs

A
  • most hospitals and national chains have corporate compliance departments
  • monitor federal law and rules/regs
  • to protect the organization, not necessarily the individual
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15
Q

OIG

A

-office of inspector general

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16
Q

Reason for Tax Exempt Status

A
  • government allows hospitals to be tax-exempt in order for them to use the money for community benefit
  • profits must be put back into the organization
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17
Q

Inurement can be:

A
  • money
  • payment in kind, such as for continuing edu
  • low rent or rent-free office space
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18
Q

Inurement

A

-

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19
Q

Stark 2 Law

A
  • intent to prevent physician ownership of PT/OT clinics, DME companies, O2 suppliers, & hospital inpatient or outpatient services
  • has large loopholes and exceptions
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20
Q

Starks 2 Law Loopholes

A
  • physicians can own PT and OT clinics as long as they’re in the physician clinic and physician bills those as incident to his own
  • still must be performed by PT, OT, SLP (PTA can’t work directly under physician and bill medicare)
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21
Q

Negligent Torts

A

-failure to use such care as a reasonably prudent and careful person would use under the same or similar circumstances

(malfeasance, misfeasance, nonfeasance)

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22
Q

Malfeasance

A

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

ex. PT treating appendicitis with surgery

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23
Q

Misfeasance

A

doing something stupid

ultrasound on temples

24
Q

Nonfeasance

A

should have taken action but did not

not referring to ER when needed

25
Q

Malpractice

A
  • doing wrong when practitioner should have known to do it correctly
  • most have unintentional tort
26
Q

Negligence

A
  • ordinary

- gross

27
Q

Ordinary Negligence

A

-reasonable man

28
Q

Gross Negligence

A
  • intentional or reckless omission

- intentional tort

29
Q

Proving Negligence (4)

A
  1. duty of care
  2. breach of that duty of care
  3. injury
  4. causation/proximate cause
30
Q

Duty of Care

A

-legal relationship between the parties which imposes an obligation of care, performance or observance

31
Q

Breach of Duty of Care

A
  • determined by jury

- did provider fail to meet his/her duty?

32
Q

Injury

A
  • loss of income
  • medical expenses
  • loss of reputation
  • pain and suffering
33
Q

Causation/Proximate Cause

A

-plaintiff must prove that, absent the defendant’s negligent act, the plaintiff would not have been injured

34
Q

Burden of Truth: Civil trial

A

-must prove guilt is more likely than not

35
Q

Burden of Truth: Criminal trial

A

-must prove guilt beyond a reasonable doubt

36
Q

Standard of Care

A
  • both sides in a malpractice case will try to establish what the standard of care is
  • expert witnesses can be brought in
  • standard of care is higher for professionals (PTs)
37
Q

Expert Witnesses

A
  • strict community standards

- national standards

38
Q

Strict Liability

A
  • seller liable for any and all defective hazardous products or services which unduly threaten a consumer’s safety, regardless of fault
  • applies even if seller has exercised all possible care in the preparation and sale of his product/service
39
Q

Respondeat Superior

A

-master is responsible of actions of servant (employer responsible of employee)

40
Q

Imputed Knowledge

A

-doctrine of respondeat superior attaches liability to the organiztion regardless of whether employer has knowledge of specific act

41
Q

Title VII of Civil Rights Act of 1964

A

-made it illegal for an employer to deny anyone a job because of: race, color, religion, sex, national origin

42
Q

Title VII of Civil Rights Act of 1964 Also Prohibits:

A

-discrimination in firing, promoting, training, setting of wages/salary, and all other privileges of employment

43
Q

Questions you can’t ask in interview

A
  • do you have children?
  • plan to become pregnant?
  • married?
  • nationality?
  • disabled?
  • suffered from a disability?
44
Q

Age discrimination in employment act of 1967

A

-prohibits discrimination against people over 40 years old

45
Q

Equal Pay Act of 1963

A
  • protects men and women who perform substantially equal work in the same establishment from sex-based wage discrimination
  • can’t differentiate pay based on gender
46
Q

ADA

A
  • Americans with disabilities act
  • prohibit employment discrim based on disability
  • must have reasonable accommodations to person if it’s not an undue hardship to organization
47
Q

FMLA

A
  • Family & Medical Leave Act
  • covered employers must grant to eligible employees up to a total of 12 work weeks of unpaid leave during any 12-month period for one of several reasons
48
Q

FMLA Reasons

A
  • birth and care of newborn child of the employee
  • placement with employee of a son/daughter for adoption or foster care
  • to care for an immediate family member (spouse, child, parent) with a serious health condition
  • to take medical leave when employee is unable to work because of a serious health condition
49
Q

FMLA Qualifications

Employees Must:

A
  • have worked at organization for 1 year

- have worked minimum of 1,250 hours in that calendar year (not qualify if working <24 hours/week)

50
Q

(FMLA) for qualified employees who go on leave________

A

-the organization can’t replace them

51
Q

FLSA

A
  • fair labor standards act
  • establish federal minimum wage, overtime pay, recordkeeping, and child labor standards affecting full and part time workers in private sector, federal, state and local governments
52
Q

Covered non-exempt workers are entitled to $______/hour

A

$7.25

53
Q

covered non-exempt workers are entitled to overtime pay at rate of not less than ______

A

1.5 times their regular pay rates of pay after 40 hours of work in a work week

54
Q

FLSA Exempt Workers

A

-salaried (exempt), hourly (Non-exempt)

55
Q

Salaried staff are usually paid for _____/week

A

40 hours/week no matter how many hours worked (30 or 80 etc)

56
Q

Must Qualify to be Salaried:

A
  • executive
  • administrative
  • professional (PT)
  • outside sales & computer employees
57
Q

FLSA does not require:

A
  • vacations/vacation pay
  • holidays or holiday pay
  • severance pay
  • sick pay
  • meal or rest periods
  • premium pay for weekends/holidays
  • pay raises
  • fringe benefits
  • termination notice or immediate payment of final wages

Healthcare Management (11 decks)

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