CPMA Certification Study Guide 2018 Chapter 1. Questions and answers, rated A+

CPMA Certification Study Guide 2018 Chapter 1. Questions and answers, rated A+ How does CMS define fraud? - -Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program. How does CMS define abuse? - -An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Example of Fraud - -Billing for services and/or supplies that you know were not furnished or provided Altering claim forms and/or receipts to receive a higher payment amount Billing for services at a higher level than provided or necessary Misrepresenting the diagnosis to justify payment CMS Examples of Abuse - -Misusing codes on a claim Charging excessively for services or supplies Billing for services that were not medically necessary Failure to maintain adequate medical or financial records Improper billing practices Billing Medicare patients a higher fee schedule than non-Medicare patients Federal False Claims Act - -A law that allows for individuals to bring civil actions on behalf of the U.S. government for false claims made to the federal government, under a provision of the law called qui tam (from Latin meaning "to bring an action for the king and for oneself"). Examples of fraud or misconduct subject to the False Claims Act include: - -Falsifying a medical chart notation Submitting claims for services not performed, not requested, or unnecessary Submitting claims for expired drugs Upcoding and/or unbundling services Submitting claims for physician services performed by a non-physician provider without regard to Incident-to guidelines The FCA allows for reduced penalties (mitigation) if the person committing the violation self-discloses, and if: - -* the person responsible furnishes officials of the U.S. responsible for investigating false claims violations with all information known to such person about the violation within 30 days after the date on which the defendant first obtained the information * such person fully cooperates with the investigation of such violation * at the time such person furnishes the information about the violation, no criminal prosecution, civil action, or administrative action has commenced under this title with respect to such violation, and the person did not have actual knowledge of the existence of an investigation into such violation Qui Tam Action - -An action to recover a penalty brought on by an informer in a situation in which one portion of the recovery goes to the informer and the other portion to the state or government. What defines a financial relationship among entities? - -a direct or indirect ownership interest, investment interest, or compensation arrangement with any entity that furnishes a DHS What is the Stark Law? - -prohibits a physician from referring patients for certain designated health services (Medicare & Medicaid) to entities with whom the physician has a financial relationship What is the Anti-Kickback law? - -Similar to Stark Law but imposes more severe penalties. States that whoever knowingly and willfully solicits or receives any remuneration: a) In return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a federal healthcare program, or... b) In return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a federal healthcare program... ...shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five year, or both. What is the Exclusion Statute? - -Physicians may be banned from participation in Federal or state health care programs such as Medicare, Medicaid, TRICARE (military), and Veterans Health. The provider cannot bill either as participating or non-participating provider. The ban applies to the excluded individual or entity, anyone who employs or contracts with the excluded person, any hospital or other provider for which the excluded person provides services, and any other provider or supplier. No payments will be made for anything that the excluded person prescribes. The length of exclusion will be at least 5 years. What is the Civil Monetary Penalties Law (CMPL)? - -A law tdhat states that any person is in violation if he or she knowingly presents, or causes to be presented, a claim to any federal or state agency that the Secretary of HHS determines : * is for a medical service or other item or service that the person knows or should know was not provided as claimed (upcoding,miscoding,etc.) * is for a medical or other item or service and the person knows or should know the claim is false or fraudulent * is presented for a physician's service, or item or service incident-to a physician's serice, by a person who knows or should know that the individual who furnished or supervised the service was not a licensed physician, was a licensed physician but with a license obtained through a misrepresentation of material fact, or represented to the patient at the time the services was furnished that the physician was certified in a medical specialty by a medical specialty board when the individual was not so certified *is for a medical or other service that was furnished during a period in which the person was excluded from the federal healthcare program under which the claims were made *is for a pattern of medical or other items or services that a person knows or should know are not medically necessary. OIG Work Plan - -lists the various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General Corporate Integrity Agreement (CIA) - -A compliance program imposed by the government, which involves substantial government oversight and outside expert involvement in the organization's compliance activities and is generally required as a condition of settling a fraud and abuse investigation What is a compliance plan? - -comprehensive documentation that a provider, practice, facility or other healthcare entity is taking steps to adhere to the federal and state laws that affect it. What are the seven elements that should be present in every compliance plan? - -1)Implementing written policies, procedures, and standards of conduct