Test 5 Part 25

Question 1

Illegal to restrain trade through contracts or conspiracies, and they prohibit price fixing and mergers that lessen competition

Federal Trade Commission (FTC) and the Department of Justice enforce these laws

Answer 1

Sherman Antitrust Act

Question 2

Under the Sherman Antitrust Act, Healthcare mergers and joint ventures and ____________ and peer review processes must be carefully handled to avoid anti-trust issues

Answer 2

credentialing

Question 3

Application of CMP provisions beyond those funded by HHS to include all federal healthcare programs (e.g., Tricare, Veterans Affairs, and Public Health Service)

Strengthened the OIG’s CMP penalties for violations under Medicare

Answer 3

HIPAA—Expanded OIG

Question 4

Expanded funding of enforcement efforts

Expansion of RACs to Medicare Part C & D and Medicaid

Added penalties

Requiring Medicare and Medicaid overpayments to be returned in 60 days

Answer 4

Patient Protection and Affordable Care Act (ACA)

Question 5

OIG is required to exclude providers and suppliers convicted of:
Medicare fraud
Patient abuse or neglect
Felony convictions related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of a healthcare item or service
Felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances
OIG has the discretion to impose exclusions for other reasons

Answer 5

Exclusion Statue

Question 6

Billing for noncovered services
Altered claim forms
Duplicate billing
Misrepresentation of facts on claim form
Failing to return overpayments
Unbundling
Billing for medically unnecessary services
Overcoding or upcoding
Billing for items or services not rendered
False cost reports

Answer 6

High-Risk Areas for Potential Fraud and Abuse

Question 7

High Risk, Problem Prone, High Volume cases of fraud and abuse should be ______ and ________.

Answer 7

audited and monitored

Question 8

Healthcare Fraud and Abuse Control (HCFAC) program goal is to _______ state, federal, and local fraud and abuse activities

Answer 8

coordinate

Question 9

__________________ goal is to be proactive in identifying fraud

Answer 9

Healthcare Fraud Prevention Partnership (HFPP)

Question 10

Root out fraud and safeguard taxpayers from illegal conduct

Works in collaboration with a number of other federal agencies to investigate and prosecute fraudulent activities

Answer 10

Role of Department of Justice(DOJ)