FWA - Medicare Fraud, Waste, & Abuse. Top Exam Questions and answers, 100% Accurate.

FWA - Medicare Fraud, Waste, & Abuse. Top Exam Questions and answers, 100% Accurate. A chiropractor, in an intentional attempt to falsely get Medicare Program money, billed medically unnecessary services and falsified the beneficiary's Medicare claim diagnosis. Depending on the facts and circumstances, she most likely committed - -Medicare fraud or abuse because she knowingly submitted false Medicare Program claims You can help prevent Medicare fraud & abuse by - -All of the above Medicare abuse includes any practice inconsistent with the goals of providing patients with all requested services, meeting professionally recognized standards, and charging fair prices. - -True You can help prevent Medicare fraud & abuse by properly and thoroughly documenting all services provided to Medicare beneficiaries - -True Select the true statement - -MACs, CERT Contractors, and Recovery Audit Program Recovery Auditors review only claims and generally do not investigate health care providers suspected of Medicare fraud & abuse Health care providers can prevent fraud & abuse in the Medicare Program by - -All of the above You may report suspected fraud & abuse anonymously to the Office of Inspector General (OIG) via - -All of the above Possible Medicare fraud & abuse penalties include - -A, B, and C The Federal laws that address fraud & abuse include - -All of the above Health care providers use the Self-Referral Disclosure Protocol (SRDP) to report all suspected fraud & abuse - -True Center for Medicare and Medicaid Services (CMS) The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program, and health insurance portability standards. Waste Incurring unnecessary costs as a result of deficient management, practices, or controls Fraud Obtaining a benefit through intentional misrepresentation or concealment of material facts Abuse Excessively or improperly using government resources False Claims Act Prohibits the submission of false or fraudulent claims to the Government Anti-Kickback Statute The AKS, 42 U.S.C. Section 1320a-7b(b), makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program. Exclusion Statute The Exclusion Statute is the law which is used by the OIG to impose sanctions on individuals or entities. Civil Monetary Penalties Law Authorizes the HHS to impose civil money penalties and/or exclude from the Medicare and Medicaid programs physicians who commit various forms of fraud and abuse involving Medicare and Medicaid. Example of Anti-Kickback Statute A provider receives cash or below-fair-market-value rent for medical office space in exchange for referrals. Anti-Kickback Statute (AKS) Penalties Criminal penalties and administrative sanctions for violating the AKS may include fines, imprisonment, and exclusion from participation in the Federal health care program. Under the CMPL, penalties for violating the AKS may include three times the amount of the kickback, plus up to $100,000 (in 2018) per kickback. Safe Harbor Regulations The "safe harbor" regulations, 42 Code of Federal Regulations (C.F.R.) Section 1001.952, describe various payment and business practices that, although they potentially implicate the AKS, are not treated as offenses under the AKS if they meet certain requirements. Physician Self-Referral Statute The Physician Self-Referral Law, 42 U.S.C. Section 1395nn, often called the Stark Law, prohibits a physician from referring patients to receive "designated health services" payable by Medicare or Medicaid to an entity with which the physician or a member of the physician's immediate family has a financial relationship, unless an exception applies. Example of Self- Referral Law (Stark Law) A physician refers a beneficiary for a designated service to a clinic where the physician has an investment interest. Penalties for violations of the Physician Self-Referral Law Penalties for physicians who violate the Stark Law may include fines, CMPs up to $24,478 (in 2018) for each service, repayment of claims, and potential exclusion from participation in the Federal health care programs. Criminal Health Care Fraud Statute The Criminal Health Care Fraud Statute, 18 U.S.C. Section 1347 prohibits knowingly and willfully executing, or attempting to execute, a scheme or lie in connection with the delivery of, or payment for, health care benefits, items, or services to either: ● Defraud any health care benefit program ● Obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the control of, any health care benefit program Penalties for violating the Criminal Health Care Fraud Statute Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both. Office of Inspector General's (OIG) The OIG protects the integrity of HHS' programs and the health and welfare of program beneficiaries. The OIG operates through a nationwide