CPCO CH. #4 EXAM QUESTIONS AND
ANSWERS
In a qui tam action in which the government intervenes, the relator is entitled to receive
a monetary settlement between? - ANSWER-15- 25%
The Civil Monetary Penalty Law and the False Claims Act (FCA)—are related to proper
claims filing. Mere mistakes, which can be remedied by returning overpayments... -
ANSWER-do not result in violations of these laws.
Federal wire fraud (18 USC 1343) covers - ANSWER-any criminal fraudulent activity
that is determined to involve electronic communications of any kind. The citation
specifically states: "Whoever, having devised or intending to devise any scheme or
artifice to defraud, or for obtaining money or property by means of false or fraudulent
pretenses, representations, or promises, transmits or causes to be transmitted by
means of wire, radio, or television communication in interstate or foreign commerce, any
writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or
artifice, shall be fined under this title or imprisoned not more than 20 years, or both."
This type of fraud involves such activities as transmitting claims for reimbursement
through the Internet or Facsimile. It can also include telephone solicitation when fraud is
the objective such as in the case of Medicare Parts C and D programs, supplemental
insurance plans, private insurance programs, and DME solicitation. Fraudulent claims
submitted electronically across state lines or internationally have the potential to be in
violation of this statute.
Stark Law - ANSWER-prohibits payments for certain "Designated Health Services"
provided through a prohibited referral and requires refunds for any amounts improperly
billed and collected. It provides for a civil monetary penalty (up to $15,000 per service)
and exclusion from government programs in any case where a person submits an
improper claim, which was known to have been, or should have been known to have
been, provided through a prohibited referral, and has not refunded the payment.
Two laws—the Anti-Kickback Statute and the Stark Law—relate... - ANSWER-primarily
to the relationships between referral sources, such as physicians and hospitals.
Anti-Kickback Statute - ANSWER-it is a felony to knowingly and willfully offer, pay,
solicit, or receive anything of value (remuneration) in return for a referral, or to induce
generation of business reimbursable under a federal healthcare program. The statute
prohibits both the offer or payment of remuneration for patient referrals, and the offer or
payment of anything of value in return for purchasing, leasing, ordering, arranging for, or
recommending the purchase, lease, or ordering of any item or service that is
reimbursable by a federal healthcare program.
, Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for
employing excluded entities or providers. How often should he check the OIG List of
Excluded Individuals Entities on the OIG website? - ANSWER-Prior to hiring and
monthly thereafter
So-called "circumnavigation schemes" may result in - ANSWER-monetary penalties of
up to $100,000 for each arrangement or scheme, and exclusion from government
programs. These occur when a physician or other entity enters an arrangement or
scheme (such as a cross-referral arrangement) that the entity or person knew, or should
have known, had the principal purpose of assuring referrals (which, if they had been
made directly, would have been prohibited).
When you find out that someone is excluded from federal programs, consider the
following steps: - ANSWER-• At least temporarily remove them from providing services.
Discuss whether that will include all services or just government program services with
your legal counsel.
• Any paperwork regarding the exclusion should be reviewed and the individual should
only be returned to duty when there is documentation of government reinstatement.
• An analysis should be done to first determine whether the person or entity was
properly excluded, and the correct timeframe. Then the items or services they ordered
or prescribed would be examined.
• If items or services are not ordered or prescribed, the excluded person's salary,
benefits, or contract cost would be analyzed to determine if they affect payment under a
Medicare or Medicaid cost report.
The Compliance Officer at Apple Internal Medicine Group explains to the Board that
there is a difference between the False Claims Act (FCA) Civil and Criminal law. What is
the difference between them? - ANSWER-Criminal states that proof must be beyond a
reasonable doubt.
The FCA does not encompass mistakes, errors, or negligence. For criminal penalties,
the standard is even higher—criminal intent to defraud must be proved beyond a
reasonable doubt.
False Claims Act covers claims that are billed to - ANSWER-Medicare A,B,C, & D
Providers can give physicians gifts and other benefits up to a set amount each year,
adjusted for inflation. Gifts and benefits should be tracked: If the set amount is
exceeded, what can the physician do? - ANSWER-Repay the excess.
Exclusion can result from violating any section of the Civil Monetary Penalties Law, or
from an individual or entity submitting a claim for reimbursement to a federal health care
program for items or services furnished by an excluded person or entity. Penalties can
be up to how much (prior to inflation)? - ANSWER-$11,000 per claim, plus treble
damages for the amount claimed for each item or service.
ANSWERS
In a qui tam action in which the government intervenes, the relator is entitled to receive
a monetary settlement between? - ANSWER-15- 25%
The Civil Monetary Penalty Law and the False Claims Act (FCA)—are related to proper
claims filing. Mere mistakes, which can be remedied by returning overpayments... -
ANSWER-do not result in violations of these laws.
Federal wire fraud (18 USC 1343) covers - ANSWER-any criminal fraudulent activity
that is determined to involve electronic communications of any kind. The citation
specifically states: "Whoever, having devised or intending to devise any scheme or
artifice to defraud, or for obtaining money or property by means of false or fraudulent
pretenses, representations, or promises, transmits or causes to be transmitted by
means of wire, radio, or television communication in interstate or foreign commerce, any
writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or
artifice, shall be fined under this title or imprisoned not more than 20 years, or both."
This type of fraud involves such activities as transmitting claims for reimbursement
through the Internet or Facsimile. It can also include telephone solicitation when fraud is
the objective such as in the case of Medicare Parts C and D programs, supplemental
insurance plans, private insurance programs, and DME solicitation. Fraudulent claims
submitted electronically across state lines or internationally have the potential to be in
violation of this statute.
Stark Law - ANSWER-prohibits payments for certain "Designated Health Services"
provided through a prohibited referral and requires refunds for any amounts improperly
billed and collected. It provides for a civil monetary penalty (up to $15,000 per service)
and exclusion from government programs in any case where a person submits an
improper claim, which was known to have been, or should have been known to have
been, provided through a prohibited referral, and has not refunded the payment.
Two laws—the Anti-Kickback Statute and the Stark Law—relate... - ANSWER-primarily
to the relationships between referral sources, such as physicians and hospitals.
Anti-Kickback Statute - ANSWER-it is a felony to knowingly and willfully offer, pay,
solicit, or receive anything of value (remuneration) in return for a referral, or to induce
generation of business reimbursable under a federal healthcare program. The statute
prohibits both the offer or payment of remuneration for patient referrals, and the offer or
payment of anything of value in return for purchasing, leasing, ordering, arranging for, or
recommending the purchase, lease, or ordering of any item or service that is
reimbursable by a federal healthcare program.
, Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for
employing excluded entities or providers. How often should he check the OIG List of
Excluded Individuals Entities on the OIG website? - ANSWER-Prior to hiring and
monthly thereafter
So-called "circumnavigation schemes" may result in - ANSWER-monetary penalties of
up to $100,000 for each arrangement or scheme, and exclusion from government
programs. These occur when a physician or other entity enters an arrangement or
scheme (such as a cross-referral arrangement) that the entity or person knew, or should
have known, had the principal purpose of assuring referrals (which, if they had been
made directly, would have been prohibited).
When you find out that someone is excluded from federal programs, consider the
following steps: - ANSWER-• At least temporarily remove them from providing services.
Discuss whether that will include all services or just government program services with
your legal counsel.
• Any paperwork regarding the exclusion should be reviewed and the individual should
only be returned to duty when there is documentation of government reinstatement.
• An analysis should be done to first determine whether the person or entity was
properly excluded, and the correct timeframe. Then the items or services they ordered
or prescribed would be examined.
• If items or services are not ordered or prescribed, the excluded person's salary,
benefits, or contract cost would be analyzed to determine if they affect payment under a
Medicare or Medicaid cost report.
The Compliance Officer at Apple Internal Medicine Group explains to the Board that
there is a difference between the False Claims Act (FCA) Civil and Criminal law. What is
the difference between them? - ANSWER-Criminal states that proof must be beyond a
reasonable doubt.
The FCA does not encompass mistakes, errors, or negligence. For criminal penalties,
the standard is even higher—criminal intent to defraud must be proved beyond a
reasonable doubt.
False Claims Act covers claims that are billed to - ANSWER-Medicare A,B,C, & D
Providers can give physicians gifts and other benefits up to a set amount each year,
adjusted for inflation. Gifts and benefits should be tracked: If the set amount is
exceeded, what can the physician do? - ANSWER-Repay the excess.
Exclusion can result from violating any section of the Civil Monetary Penalties Law, or
from an individual or entity submitting a claim for reimbursement to a federal health care
program for items or services furnished by an excluded person or entity. Penalties can
be up to how much (prior to inflation)? - ANSWER-$11,000 per claim, plus treble
damages for the amount claimed for each item or service.
