HCQM - Regulatory Environment: Questions & Answers
Medicare Part A Right Ans - Pays for inpatient hospital, SNF, HH related
to hospital stay, and hospice care. Financing comes from a 2.9% payroll tax
split between employers and employees.
Medicare Part B Right Ans - Pays for physician, outpatient hospital,
ESRD, lab, DME, and some HH. Coverage is voluntary - about 92% of
beneficiaries are enrolled. 25% is covered by beneficiary premiums/75%
other government revenues
Medicare Part C Right Ans - Medicare Advantage Program - typically
private managed care companies are paid capitation by the government to
provide all Part A, B, & D services.
Medicare Part D Right Ans - standard rx benefit. Beneficiaries are
responsible for a portion of the cost which varies on brand vs. generic and
how much money they have already spent on rx that year.
Elliot Fisher Right Ans - Introduced the Accountable Care Organization
and incorporated it into Medicare Shared Savings Program provisions of
the PPACA.
Accountable Care Organization Right Ans - Advocates for coordination
of health services by organizations with an intention to promote an
integrated approach to health care with efficiency and cost savings.
State Scope of Practice Restriction Right Ans - intended to ensure that
professionals offer services according to their skill and training.
Stark Law Right Ans - Prohibits physicians from referring patients for
designated health services where there is a financial relationship between
the providers. CMS publishes a list of CPT codes on an annual basis that
identify DHS services.
Federal Anti-Kickback Statute Right Ans - Prohibits providing
remuneration or giving of value with the intent of inducing referrals.
Includes both criminal and civil penalties.
, The Federal Health Care False Claims Right Ans - May not knowingly
submit a false claim for payment - includes actual knowledge or deliberate
disregard such as when bills were submitted that would be paid for
services not rendered
Qui Tam Actions Right Ans - Part of the False Claims Act - allows a
"relator" to bring a suit on behalf of the government after filing an action
under seal. The government will review the act and choose whether to
intervene (join the suit). Individuals may continue without the government
joining if they desire. Relators will get between 15-30% of the recovery
depending on whether the government joined the case.
Corporate Practice of Medicine Right Ans - Avoids commercialization,
lay control, and limited liability of the corporate form. These professionals
should not have their actions controlled by someone else as the "patient" is
their client and their needs should dictate the relationship. Stems from the
Learned Professions Doctrine.
Financial Relationship Right Ans - ownership/investment interest (may
be through debt/equity) or a compensation arrangement (may be
direct/indirect such as an immediate family member)
Remuneration Right Ans - Any payment or benefit in cash or in kind
with the exception of forgiveness of amounts for inaccurate/mistakenly
performed services/correction of minor billing errors, provision of items
used to collect, transport, process, or store specimens for the entity
providing the service or as needed to communicate results, and certain
payments made by an insurer to the physician for services rendered to a
beneficiary
Referral Right Ans - Request by a physician for, or ordering of, or the
certifying or recertifying of the need for a covered item or service
(including consults) or the request or establishment of a plan of care by a
physician which includes the provision of DHS. It includes referrals within
the physician's own practice and can be in any form including written, oral,
or electronic. DHS is not considered performed by the physician if anyone
provides it.
Medicare Part A Right Ans - Pays for inpatient hospital, SNF, HH related
to hospital stay, and hospice care. Financing comes from a 2.9% payroll tax
split between employers and employees.
Medicare Part B Right Ans - Pays for physician, outpatient hospital,
ESRD, lab, DME, and some HH. Coverage is voluntary - about 92% of
beneficiaries are enrolled. 25% is covered by beneficiary premiums/75%
other government revenues
Medicare Part C Right Ans - Medicare Advantage Program - typically
private managed care companies are paid capitation by the government to
provide all Part A, B, & D services.
Medicare Part D Right Ans - standard rx benefit. Beneficiaries are
responsible for a portion of the cost which varies on brand vs. generic and
how much money they have already spent on rx that year.
Elliot Fisher Right Ans - Introduced the Accountable Care Organization
and incorporated it into Medicare Shared Savings Program provisions of
the PPACA.
Accountable Care Organization Right Ans - Advocates for coordination
of health services by organizations with an intention to promote an
integrated approach to health care with efficiency and cost savings.
State Scope of Practice Restriction Right Ans - intended to ensure that
professionals offer services according to their skill and training.
Stark Law Right Ans - Prohibits physicians from referring patients for
designated health services where there is a financial relationship between
the providers. CMS publishes a list of CPT codes on an annual basis that
identify DHS services.
Federal Anti-Kickback Statute Right Ans - Prohibits providing
remuneration or giving of value with the intent of inducing referrals.
Includes both criminal and civil penalties.
, The Federal Health Care False Claims Right Ans - May not knowingly
submit a false claim for payment - includes actual knowledge or deliberate
disregard such as when bills were submitted that would be paid for
services not rendered
Qui Tam Actions Right Ans - Part of the False Claims Act - allows a
"relator" to bring a suit on behalf of the government after filing an action
under seal. The government will review the act and choose whether to
intervene (join the suit). Individuals may continue without the government
joining if they desire. Relators will get between 15-30% of the recovery
depending on whether the government joined the case.
Corporate Practice of Medicine Right Ans - Avoids commercialization,
lay control, and limited liability of the corporate form. These professionals
should not have their actions controlled by someone else as the "patient" is
their client and their needs should dictate the relationship. Stems from the
Learned Professions Doctrine.
Financial Relationship Right Ans - ownership/investment interest (may
be through debt/equity) or a compensation arrangement (may be
direct/indirect such as an immediate family member)
Remuneration Right Ans - Any payment or benefit in cash or in kind
with the exception of forgiveness of amounts for inaccurate/mistakenly
performed services/correction of minor billing errors, provision of items
used to collect, transport, process, or store specimens for the entity
providing the service or as needed to communicate results, and certain
payments made by an insurer to the physician for services rendered to a
beneficiary
Referral Right Ans - Request by a physician for, or ordering of, or the
certifying or recertifying of the need for a covered item or service
(including consults) or the request or establishment of a plan of care by a
physician which includes the provision of DHS. It includes referrals within
the physician's own practice and can be in any form including written, oral,
or electronic. DHS is not considered performed by the physician if anyone
provides it.
