Preventing Fraud, Abuse, Waste

Question 1

Fraud, waste, abuse results in

Answer 1

• Over utilization of services
• increased cost for payers
• corruption of medical decision making
• unfair competition
• harm to pt

Question 2

Fraud

Answer 2

Intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled

Question 3

Examples of fraud

Answer 3

Knowingly billing for services not furnished
Knowingly altering claims forms to receive more payment
Falsifying documents

Question 4

Abuse

Answer 4

Payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment

Question 5

Examples of abuse

Answer 5

Billing services that are not medically necessary
Unbundling services and billing
Billing services that do not meet professionally recognized standards

Question 6

Waste

Answer 6

Incurring incessant costs as a result of deficient management practices, systems, or controls

Question 7

Examples of waste

Answer 7

Duplication of services already provided elsewhere

Spending on services that lack evidence of producing better outcomes compared with less-expensive alternatives

Question 8

Major fraud and abuse laws

Answer 8

• false claims act
• federal anti-kickback statute
• physical self-referral law
• exclusion authorities
• civil monetary penalty law

Question 9

False claims back prohibits

Answer 9

The knowing submission of false claims or the use of false record or statement for payment to Medicare or Medicaid

Question 10

False claims act monetary penalties

Answer 10

Between $5500 and $11000 per claim, plus 3 times the damages sustained by the government

Question 11

False claims act sanctions

Answer 11

License sanctions and exclusions from federal program (you can be black listed)

Question 12

“Knowing” under false claims act

Answer 12

Includes actual knowledge, deliberate ignorance, and reckless disregard for the truth or falsity of the information (you can’t choose to ignore information)

Question 13

False claims act and whistleblowers

Answer 13

Strong incentive to report—-up to 30% of recovery

Question 14

Who can be a false claim act whistleblower?

Answer 14

Ex-business partners
Staff
Competitors
Patients

Question 15

Anti-kickback stature prohibits

Answer 15

Anyone from knowingly or willfully offering or receiving a form of payment in return for referring a patient to another provider for services or items covered by Medicare and Medicaid (applies to both payer and recipient)

Question 16

Anti-kickback statute payment includes

Answer 16

Anything of value

-cash for referrals, free rent, gifts, etc

Question 17

Kickback examples

Answer 17

Pt gives referrer free/discounted office space
DME pays cash/provides free/discounted equipment in exchange for “preferred vendor status”
PT discounts/waives patient payment responsibility

Question 18

Physical self-referral law

Answer 18

Prohibits physical referrals for certain health care services when there is a financial relationship with an entities unless an exception applies (financial relationships include ownership and compensation)

Question 19

Stark laws

Answer 19

Is there a referral by a physician for a designated health service payable by Medicare?—> then does the physician have a financial relationship with the entity furnishing the DHS? —> if so, does the financial relationship if in an exception?—>if not, there is a violation

Question 20

Exclusion statue for physician self-referral law

Answer 20

The government may exclude inviolate providers from participation in federal health care programs meaning:

• provider may not pill for txing pts
• employer may not bill for the provider’s service

Question 21

PT relationship with payers

Answer 21

• coding and billing
• documentations
• enrollment

Question 22

Coding and billing for PT

Answer 22

• payers rely on PT to submit proper claims for payment c accurate info
• when fed gov pays for services for Medicare/Medicaid beneficiaries, federal fraud and abuse laws apply
• for private payers, states may have similar laws that apply

Question 23

Examples of improper coding and billing

-billing for services:

Answer 23

• not provided
• that are not medically necessary
• provided by an aide
• provided by PTAs not properly supervised

Question 24

Documentation is

Answer 24

A professional responsibility and legal requirement.
A record of patient care
Communication vehicle among providers

Question 25

Documentation: PTs must

Answer 25

Support the claims they submit with complete medical records and documentation

Question 26

Documentation: payers may

Answer 26

Review the medical records to verify the claims and quality of care through audits

Question 27

PT documentation demonstrates

Answer 27

- compliance with federal, state, payer, and local regulations - appropriate utilization

Question 28

Medicare has ID following problems with PT documentation missing

Answer 28

Or incomplete POC physicians sig and dates total time for procedures and modalities Certification and recert of POC

Question 29

Enrolling as Medicare/Medicaid provider | PT in private practice

Answer 29

Should individually enroll in federal health care programs to be paid for services to Medicare/Medicaid beneficiaries

Question 30

PTs enrolled in Medicare/Medicare are

Answer 30

responsible for making sure correct claims are submitted and for updating enrollment for any changes

Question 31

If a health care business offers something for free or below fair market value, or offers cash in exchange for referrals, question:

Answer 31

- am I getting paid by company for very little work? Do they need my expertise? - does the amount of money I am offered seem appropriate for services I am going to provide? - am I being asked to refer pts to that particular company?

Question 32

Rental of office spay from physicians

Answer 32

- do not pay for more space than necessary | - do not pay greater than fair market value

Question 33

Medical directors

Answer 33

- should actively oversee clinical care, be involved - should be paid fair market value - should spend an appropriate amount of time providing services

Question 34

Gifts to physicians

Answer 34

Can be considered an inducement to refer patients to your practice -stark II law allows nominal gifts Analyze on case by case bases (education? Intent to induce referrals?)

Question 35

PT relationship with pts

Answer 35

Gifts to pts Waiver of coinsurance Collecting cash from Medicare beneficiaries

Question 36

Gifts to Medicare/Medicaid beneficiaries

Answer 36

Federal laws generally prohibit this | Seen as inducing a patient to come to your practice instead of another

Question 37

Inexpensive gifts allowed to pts if

Answer 37

Not cash or cash equivalents AND Value no more than $10 individually/$50 in aggregate annually per pt

Question 38

Why is providing free services to pts or waiving coinsurance/deductibles generally prohibited?

Answer 38

May influence a pt to receive your services (anti-kickback) | -exception for financially needy pts

Question 39

Exceptions to discounts/waiver violations

Answer 39

-provider ones not advertise discounts or waivers of copay -provider does not routinely waive copays -provider shows extensive efforts to collect money from pt OR -pt meets federal poverty guidelines or facility-specific poverty/catastrophic guidelines

Question 40

Exceptions for discounts: OIG and HHS issued letters to hospitals 02/04

Answer 40

Discount to uninsured and underinsured okay Must establish policy and apply it uniformly Documentation important

Question 41

Medicare and out of pocket

Answer 41

PT may not collect out of pocket payment from Medicare beneficiary for a service Medicare would cover (claim submission requirements under Medicare) Only exception: physician that agree to opt out and not bill Medicare for 2 years

Question 42

Compliance programs

Answer 42

Prevent fraud, abuse, waste | Guidance is available for OIG

Question 43

Core elements of compliance program 1-4

Answer 43

1. Written standards of conduct, policies, and procedures 2. Designation of a compliance officer 3. Effective education and training programs 4. Hotline to receive complaints

Question 44

Core elements of compliance program 5-7

Answer 44

5. System to repsonse to allegations of improper and or illegal activities 6. Audits to monitor compliance 7. Investigation and remediation of identified systematic problems

Question 45

What to do if there is a compliance problem

Answer 45

- contact compliance officer - immediately stop submitting problematic bills - Seek knowledgeable legal counsel - determine whether there are any overpayments that need to be returned - disentangle yourself form problematic relationship - when appropriate consider reporting info to OIG or CMS