AHFI Exam | 168 Questions and Answers
The Stark Law (42 US SS 139nn) Prohibition - ANSWER -Prohibits a physician
from referring Medicare patients for designated health services to an entity with
which the physician (or immediate family member) has a financial relationship,
unless an exception applies)
Prohibits the designated health services entity from submitting claims to Medicare
for those services resulting from a prohibited referral
The Stark Law (42 US SS 139nn) Referrals - ANSWER -Referrals from a
physician
The Stark Law (42 US SS 139nn) (Items/Services) - ANSWER -Designated health
services
The Stark Law (42 US SS 139nn) (Intent) - ANSWER -No intent standard for
overpayment (strict liability)
Intent required for civil monetary penalties for knowing violations
The Stark Law (42 US SS 139nn) (Civil Penalties) only - ANSWER -
Overpayment/refund obligation
False Claims Act liability
Civil monetary penalties and program exclusion for knowing violations
Potential $15,000 CMP for each service
Civil assessment of up to 3x the amount claimed.
The Stark Law (42 US SS 139nn) (Exceptions) - ANSWER -Mandatory
exceptions
,The Stark Law (42 US SS 139nn) applies to - ANSWER -Medicare and Medicaid
(No commercial or tricare)
MACs: - ANSWER -Medicare Administrative Contractors
They analyze claims to determine provider compliance with Medicare coverage,
coding, and billing rules and take appropriate corrective action when providers are
found to be non-compliant.
The goal of Mac administrative actions - ANSWER -To correct the behavior in
need of change and prevent future inappropriate billing
The priority of MACs - ANSWER -To minimize potential future losses to the
Medicare Trust Fund through targeted claims review while using resource
efficiently and treating providers and beneficiaries fairly.
For repeated infractions, MACs have - ANSWER -The discretion to initiate
progressively more severe administrative action, commensurate with the
seriousness of the identified problem. (See Program Integrity Manual (PIM)
chapter 3, SS3. 7.1)
Medicare Fee For Service Recovery Audit Program - ANSWER -Legislative
mandated program (Tax Relief and Health Care act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by Medicare to
feefor-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
, Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - ANSWER -
False Claims act liability
Civil monetary penalties and program exclusions
Potential $50,000 CMP/violation
Civil assessment of up to 3x amount of kickback
Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - ANSWER Voluntary
safe harbors
Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - ANSWER
All Federal Health Care Programs
MACs targeted provider-specific prepayment review - ANSWER -The MACs
shall initiate a targeted provider-specific prepayment review only when there is the
likelihood of sustained or high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review to prevent
improper payments for services identified by C ERT or Recovery Auditors as
problem areas, as well as, problem areas identified by their own data analysis
Cert Contractors and reviews - ANSWER -Because the Cert Contractors select
claims on a random basis, they are not required to notify providers of their
intention to begin a review.
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - ANSWER -Prohibits
offering, paying, soliciting or reviving anything of value to induce or reward
referrals or generate Federal health care program business
Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - ANSWER -Referrals
from anyone
The Stark Law (42 US SS 139nn) Prohibition - ANSWER -Prohibits a physician
from referring Medicare patients for designated health services to an entity with
which the physician (or immediate family member) has a financial relationship,
unless an exception applies)
Prohibits the designated health services entity from submitting claims to Medicare
for those services resulting from a prohibited referral
The Stark Law (42 US SS 139nn) Referrals - ANSWER -Referrals from a
physician
The Stark Law (42 US SS 139nn) (Items/Services) - ANSWER -Designated health
services
The Stark Law (42 US SS 139nn) (Intent) - ANSWER -No intent standard for
overpayment (strict liability)
Intent required for civil monetary penalties for knowing violations
The Stark Law (42 US SS 139nn) (Civil Penalties) only - ANSWER -
Overpayment/refund obligation
False Claims Act liability
Civil monetary penalties and program exclusion for knowing violations
Potential $15,000 CMP for each service
Civil assessment of up to 3x the amount claimed.
The Stark Law (42 US SS 139nn) (Exceptions) - ANSWER -Mandatory
exceptions
,The Stark Law (42 US SS 139nn) applies to - ANSWER -Medicare and Medicaid
(No commercial or tricare)
MACs: - ANSWER -Medicare Administrative Contractors
They analyze claims to determine provider compliance with Medicare coverage,
coding, and billing rules and take appropriate corrective action when providers are
found to be non-compliant.
The goal of Mac administrative actions - ANSWER -To correct the behavior in
need of change and prevent future inappropriate billing
The priority of MACs - ANSWER -To minimize potential future losses to the
Medicare Trust Fund through targeted claims review while using resource
efficiently and treating providers and beneficiaries fairly.
For repeated infractions, MACs have - ANSWER -The discretion to initiate
progressively more severe administrative action, commensurate with the
seriousness of the identified problem. (See Program Integrity Manual (PIM)
chapter 3, SS3. 7.1)
Medicare Fee For Service Recovery Audit Program - ANSWER -Legislative
mandated program (Tax Relief and Health Care act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by Medicare to
feefor-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
, Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - ANSWER -
False Claims act liability
Civil monetary penalties and program exclusions
Potential $50,000 CMP/violation
Civil assessment of up to 3x amount of kickback
Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - ANSWER Voluntary
safe harbors
Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - ANSWER
All Federal Health Care Programs
MACs targeted provider-specific prepayment review - ANSWER -The MACs
shall initiate a targeted provider-specific prepayment review only when there is the
likelihood of sustained or high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review to prevent
improper payments for services identified by C ERT or Recovery Auditors as
problem areas, as well as, problem areas identified by their own data analysis
Cert Contractors and reviews - ANSWER -Because the Cert Contractors select
claims on a random basis, they are not required to notify providers of their
intention to begin a review.
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - ANSWER -Prohibits
offering, paying, soliciting or reviving anything of value to induce or reward
referrals or generate Federal health care program business
Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - ANSWER -Referrals
from anyone
