CPMA Compliance and Regulatory
Guidelines (Ch 1) Questions And Answers
Abuse * CMS defines as an action resulting in unnecessary costs to a federal healthcare
program, either directly or indirectly.
* Unnecessary costs
* Examples include:
1) Misusing codes on a claim.
2) Charging excessively for services or supplies.
3) Billing for services that were not medically necessary.
4) Failure to maintain adequate medical or financial records.
5) Improper billing practices.
6) Billing Medicare patients a higher fee schedule than non-Medicare patients.
Federal False Claims Act (FCA) Part 1 * Also called the Lincoln Law.
* Enacted in 1863 to combat fraud by suppliers of goods to the Union Army during the US Civil
War. (Defective weapons, selling sick horses or selling the same animal more than once.)
* Defines seven (7) situations where the person is liable including:
1) Knowingly present, or causes to be presented, a false or fraudulent claim for payment or
approval.
, CPMA Compliance and Regulatory
Guidelines (Ch 1) Questions And Answers
2) Knowling makes, uses, or causes to be made or used, a false record or statement material to a
false or fraudulent claim.
3) Conspires to commit a violation of any of the others.o
4) Has possession, custody, or control of property or money used, or to be used, by the
government and knowingly delivers, or causes to be delivered, less than all of that money or
property.
5) Is authorized to make or deliver a document certifying receipt of property used, or to be used,
by the government and, intended to defraud the government, make or delivers the receipt without
completely knowing that the information on the receipt is true.
6) Knowingly buys, or receives as a pledge of an obligation or debt, public property from an
officer or employee of the government, or a member of the Armed Forces, who lawfully may not
sell or pledge property.
7) Knowingly makes, uses, or causes to be made or used, a false record or statement material to
an obligation to pay or transmit money or property to the government, or knowingly conceals or
knowingly and improperly avoids or decreases an obligation to pay or transmit money or
property to the government.
Federal False Claims Act (FCA) Part 2 ** Healthcare services subject to the False Claims
Act include:
1) Falsifying a medical chart notation.
, CPMA Compliance and Regulatory
Guidelines (Ch 1) Questions And Answers
2) Submitting claims for services not performed, not requested, or unnecessary.
3) Submitting claims for expired drugs.
4) Upcoding and/or unbundling services.
5) Submitting claims for physician services performed by a non-physician provider (NPP)
without regard to incident-to guidelines.
* FCA is violated by submitting a false claim WITH KNOWLEDGE THAT IT IS FALSE even if
there is no intent to defraud.
* Cost of Violation:
1) $10,781 to $21,563 per claim, plus three times the amount of damages to the government.
2) Penalties can be reduced if the person self-discloses and:
a) provides all information within 30 days,
b) fully cooperates with the investigation, and
c) no action has commenced and no actual knowledge was present.
Whistleblower (Qui Tam) * Statute that states a person may bring concerns to the
government
* Whisteblowers get about 15-25% of the recovered amount.
Guidelines (Ch 1) Questions And Answers
Abuse * CMS defines as an action resulting in unnecessary costs to a federal healthcare
program, either directly or indirectly.
* Unnecessary costs
* Examples include:
1) Misusing codes on a claim.
2) Charging excessively for services or supplies.
3) Billing for services that were not medically necessary.
4) Failure to maintain adequate medical or financial records.
5) Improper billing practices.
6) Billing Medicare patients a higher fee schedule than non-Medicare patients.
Federal False Claims Act (FCA) Part 1 * Also called the Lincoln Law.
* Enacted in 1863 to combat fraud by suppliers of goods to the Union Army during the US Civil
War. (Defective weapons, selling sick horses or selling the same animal more than once.)
* Defines seven (7) situations where the person is liable including:
1) Knowingly present, or causes to be presented, a false or fraudulent claim for payment or
approval.
, CPMA Compliance and Regulatory
Guidelines (Ch 1) Questions And Answers
2) Knowling makes, uses, or causes to be made or used, a false record or statement material to a
false or fraudulent claim.
3) Conspires to commit a violation of any of the others.o
4) Has possession, custody, or control of property or money used, or to be used, by the
government and knowingly delivers, or causes to be delivered, less than all of that money or
property.
5) Is authorized to make or deliver a document certifying receipt of property used, or to be used,
by the government and, intended to defraud the government, make or delivers the receipt without
completely knowing that the information on the receipt is true.
6) Knowingly buys, or receives as a pledge of an obligation or debt, public property from an
officer or employee of the government, or a member of the Armed Forces, who lawfully may not
sell or pledge property.
7) Knowingly makes, uses, or causes to be made or used, a false record or statement material to
an obligation to pay or transmit money or property to the government, or knowingly conceals or
knowingly and improperly avoids or decreases an obligation to pay or transmit money or
property to the government.
Federal False Claims Act (FCA) Part 2 ** Healthcare services subject to the False Claims
Act include:
1) Falsifying a medical chart notation.
, CPMA Compliance and Regulatory
Guidelines (Ch 1) Questions And Answers
2) Submitting claims for services not performed, not requested, or unnecessary.
3) Submitting claims for expired drugs.
4) Upcoding and/or unbundling services.
5) Submitting claims for physician services performed by a non-physician provider (NPP)
without regard to incident-to guidelines.
* FCA is violated by submitting a false claim WITH KNOWLEDGE THAT IT IS FALSE even if
there is no intent to defraud.
* Cost of Violation:
1) $10,781 to $21,563 per claim, plus three times the amount of damages to the government.
2) Penalties can be reduced if the person self-discloses and:
a) provides all information within 30 days,
b) fully cooperates with the investigation, and
c) no action has commenced and no actual knowledge was present.
Whistleblower (Qui Tam) * Statute that states a person may bring concerns to the
government
* Whisteblowers get about 15-25% of the recovered amount.
