CPCO CHAPTER 4 REVIEW KEY
ENFORCEMENT LAWS EXAM
QUESTIONS WITH VERIFIED ANSWERS
Texas orthopedics submits false Medicare claims through its electronic data
interchange to its Medicare Administrative contractor based in Oklahoma. Can the
orthopedic office be charged with federal wire fraud? - ANSWER-Yes, because false
claims were submitted electronically across state lines.
Response Feedback:
Federal wire fraud (18 USC 1343) covers 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.
Judy is the front office assistant at XYZ Family Practice Group. She wants to know why
she can't waive co-pays on a regular basis if the patient can't pay. Routine waiver of co-
payments or deductibles for patients under Medicare Part B is in violation of what
Statute? - ANSWER-Anti-kickback
Response Feedback:
Examples of the Anti- kickback statute violations:
• A hospital providing rental rates that are below fair market value to a physician who
refers business to their hospital
• Routine waiver of co-payments or deductibles for patients under Medicare Part B
• A drug or equipment supplier providing free benefits for a provider who utilizes their
product
• A physician who is paid large amounts for speaking engagements by a company
whom the provider refers business to
The Office of Civil Rights (OCR) has enforcement power for violations occurring as a
result of willful neglect. The OCR can now impose civil monetary penalties of up to how
much per HIPAA privacy regulations violation. - ANSWER-$50,000
, Response Feedback:
HIPAA privacy regulations restrict the use, access, and disclosure of protected health
information (PHI) and other individually identifiable health care information. The Office
of Civil Rights (OCR) has enforcement power for violations occurring as a result of
willful neglect. The OCR can now impose civil monetary penalties of up to $50,000 per
violation.
Stark law bans certain financial arrangements between a referring physician and an
entity that bills the Medicare or Medicaid programs. An example of this is if a physician
or his ____________ has a financial relationship with an entity. - ANSWER-Wife
Response Feedback:
Immediate family member. The Stark law bans certain financial arrangements between
a referring physician and an entity that bills the Medicare or Medicaid programs.
Specifically, if a physician (or immediate family member) has a financial relationship
with an entity, the physician is prohibited from making a referral to the entity for
designated health services (DHS) for which the Medicare or Medicaid programs would
otherwise pay
The Compliance Officer at Apple Internal Medicine Group explains to the Board that
there is a difference between the FCA Civil and Criminal law. The difference is: -
ANSWER-Criminal states that proof must be beyond a reasonable doubt.
Response Feedback:
Answer is b. 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.
Which Act provides a financial incentive for states to enact false claims acts that
establish liability to the state for the submission of false or fraudulent claims to the
state's Medicaid program? - ANSWER-Deficit Reduction Act of 2005 (DEFRA)
Response Feedback:
DEFRA provides a financial incentive for states to enact false claims acts that establish
liability to the state for the submission of false or fraudulent claims to the state's
Medicaid program. If a state FCA is determined to meet certain requirements, the state
is entitled to receive a greater monetary recovery with respect to any amounts
recovered under a state action brought under such a law.
A Relator is the: - ANSWER-The Whistleblower
Response Feedback:
Civil actions may be brought in federal district court under the FCA by the attorney
general, or by a relator (whistleblower), in a qui tam action.
ENFORCEMENT LAWS EXAM
QUESTIONS WITH VERIFIED ANSWERS
Texas orthopedics submits false Medicare claims through its electronic data
interchange to its Medicare Administrative contractor based in Oklahoma. Can the
orthopedic office be charged with federal wire fraud? - ANSWER-Yes, because false
claims were submitted electronically across state lines.
Response Feedback:
Federal wire fraud (18 USC 1343) covers 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.
Judy is the front office assistant at XYZ Family Practice Group. She wants to know why
she can't waive co-pays on a regular basis if the patient can't pay. Routine waiver of co-
payments or deductibles for patients under Medicare Part B is in violation of what
Statute? - ANSWER-Anti-kickback
Response Feedback:
Examples of the Anti- kickback statute violations:
• A hospital providing rental rates that are below fair market value to a physician who
refers business to their hospital
• Routine waiver of co-payments or deductibles for patients under Medicare Part B
• A drug or equipment supplier providing free benefits for a provider who utilizes their
product
• A physician who is paid large amounts for speaking engagements by a company
whom the provider refers business to
The Office of Civil Rights (OCR) has enforcement power for violations occurring as a
result of willful neglect. The OCR can now impose civil monetary penalties of up to how
much per HIPAA privacy regulations violation. - ANSWER-$50,000
, Response Feedback:
HIPAA privacy regulations restrict the use, access, and disclosure of protected health
information (PHI) and other individually identifiable health care information. The Office
of Civil Rights (OCR) has enforcement power for violations occurring as a result of
willful neglect. The OCR can now impose civil monetary penalties of up to $50,000 per
violation.
Stark law bans certain financial arrangements between a referring physician and an
entity that bills the Medicare or Medicaid programs. An example of this is if a physician
or his ____________ has a financial relationship with an entity. - ANSWER-Wife
Response Feedback:
Immediate family member. The Stark law bans certain financial arrangements between
a referring physician and an entity that bills the Medicare or Medicaid programs.
Specifically, if a physician (or immediate family member) has a financial relationship
with an entity, the physician is prohibited from making a referral to the entity for
designated health services (DHS) for which the Medicare or Medicaid programs would
otherwise pay
The Compliance Officer at Apple Internal Medicine Group explains to the Board that
there is a difference between the FCA Civil and Criminal law. The difference is: -
ANSWER-Criminal states that proof must be beyond a reasonable doubt.
Response Feedback:
Answer is b. 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.
Which Act provides a financial incentive for states to enact false claims acts that
establish liability to the state for the submission of false or fraudulent claims to the
state's Medicaid program? - ANSWER-Deficit Reduction Act of 2005 (DEFRA)
Response Feedback:
DEFRA provides a financial incentive for states to enact false claims acts that establish
liability to the state for the submission of false or fraudulent claims to the state's
Medicaid program. If a state FCA is determined to meet certain requirements, the state
is entitled to receive a greater monetary recovery with respect to any amounts
recovered under a state action brought under such a law.
A Relator is the: - ANSWER-The Whistleblower
Response Feedback:
Civil actions may be brought in federal district court under the FCA by the attorney
general, or by a relator (whistleblower), in a qui tam action.
