Medicare Fraud and Abuse

Question 1

Error

Answer 1

incorrect billing

Question 2

Waste

Answer 2

medically unnecessary service

Question 3

Abuse

Answer 3

improper billing practices (up-coding)

Question 4

Fraud

Answer 4

billing for services or supplies that were not provided

Question 5

Anti-kickback

Answer 5

you cannot pay for referrals (induce or reward)

offering, receiving or paying

Question 6

Who is accountable for crime with anti-kickback law?

Answer 6

both parties

Question 7

Anti-kickback penalties

Answer 7

felony
fines up to $25,000
prison up to 5 years
possible exclusion from Medicare program
Possible False Claim Act (Medicare fraud and abuse liability)

Question 8

Examples of safe harbors:

Answer 8

investment interests
space and equipment rental
personal service
warranties
discounts
referral services

Question 9

Ways to protect from safe habor

Answer 9

arms length contract

fair market value

Question 10

Civil False Claims Act

Answer 10

Is the statute under which Medicare/Medicaid fraud is prosecuted

Question 11

Elements of Civil False Claims Act:

Answer 11

Submission of a claim for payment to Medicare
Claim was false or fraudulent
Claimant acted knowingly

Question 12

Also prohibited by Civil False Claims Act:

Answer 12

Using a false record to secure payment for a claim

Conspiring to secure payment for a false claim

Question 13

False Claims Act Penalties:

Answer 13

Triple the amount of damages which the government sustained because of the act of that person

Question 14

Civil penalties with false claims act:

Answer 14

$10,781-21,563 for each false claim

Question 15

Stark 2 Law:

Answer 15

Intent was to prevent physician ownership of PT/OT clinics, DME companies, oxygen suppliers, and hospital inpatient or outpatient services
Intent to prevent referral for profit

Question 16

Stark 2 Law exceptions:

Answer 16

Physicians can own PT and OT clinics as long as those clinics are within the physician clinic and the physician bills those services as “incident to” his/her own
They must be performed by a PT, OT, or SLP
PTAs cannot work directly for a physician and bill Medicare

Question 17

Malfeasance

Answer 17

doing something stupid that one is not supposed to do (e.g., practice outside the practice act)

Question 18

Misfeasance

Answer 18

doing something stupid (e.g., ultrasound on the temple)

Question 19

Nonfeasance

Answer 19

should have taken action but did not (e.g., did not refer to emergency room when necessary)

Question 20

Gross negligence

Answer 20

intentional or reckless omission

Intentional tort

Question 21

4 elements of negligence

Answer 21

Duty of Care
Breach of Duty of Care
Injury
Causation/Proximate Cause

Question 22

Duty of Care

Answer 22

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

Question 23

Breach of Duty of Care:

Answer 23

Is determined by the jury - did the defendant (provider) fail to meet his/her duty?

Question 24

Injury

Answer 24

Loss of income
Medical expenses
Loss of reputation
Pain and suffering

Question 25

Causation/Proximate Cause

Answer 25

Plaintiff must prove by a preponderance of the evidence that, absent the defendant’s negligent act, the plaintiff would not have been injured

Question 26

Malpractice:

Answer 26

doing something wrong when the practitioner should have known how to do it correctly

Question 27

What can be used to establish standard of care?

Answer 27

community standards
national standards (guide to practice)
expert witness opinion

Question 28

Strict Liability:

Answer 28

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

Question 29

Respondeat Superior

Answer 29

The master is responsible for the actions of the servant”
Hospital/nursing home/clinic is held vicariously liable for torts committed within the scope of employment of their employees

Question 30

Imputed Knowledge

Answer 30

Doctrine of respondeat superior attaches liability to the organization regardless of whether the employer has actual knowledge of the specific act

Question 31

Title VII of Civil Rights Act of 1964:

Answer 31

Made it illegal for an employer to deny anyone a job because of:
Race
Color
Religion
Sex
National Origin

Question 32

Age Discrimination in Employment Act of 1976

Answer 32

Prohibits discrimination against individuals aged 40 or over

Enforced by EEOC

Question 33

Equal Pay Act of 1963

Answer 33

Protects men and women who perform substantially equal work in the same establishment from sex-based wage discrimination

Question 34

ADA

Answer 34

Prohibits employment discrimination against qualified individuals with a disability in the private sector and in state and local governments
Must make reasonable accommodation(s) to person if it is not an undue hardship to the organization

Question 35

FMLA

Answer 35

Covered employers must grant an eligible employee up to a total of twelve (12) work weeks of unpaid leave during any 12-month period

Question 36

Reasons covered for FMLA:

Answer 36

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

Question 37

FMLA requirements:

Answer 37

a. Must have worked at organization for one (1) year
b. Must work for 1,250 hours in that calendar year
24 hours/week

Question 38

Fair Labor Standards Act

Answer 38

Establishes minimum wage, overtime pay, recordkeeping, and child labor standards affecting full-time and part-time workers in the private sector and in Federal, State, and local governments

Question 39

Qualifications for be salaried:

Answer 39

executive
administrative
professional
outside sales and computer employees

Question 40

FLSA does NOT require employers to provide

Answer 40

a. vacation, holiday, severance, or sick pay
b. meal or rest periods, holidays off, or vacations
c. premium pay for weekend or holiday work
d. pay raises or fringe benefits
e. a discharge notice, reason for discharge, or immediate payment of final wages to terminated employees