AHFI EXAM QUESTIONS & ANSWERS
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - Answer -Prohibits offering,
paying, soliciting or reviving anything of value to induce or reward referrals or generate
Federal health care program business
Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - Answer -Referrals from
anyone
Anti-Kickback Statute (42 US SS 1320a-7b (b) - Answer -Any items or services
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Intent) - Answer -Intent MUST be
proven (knowing and willful)
Anti-Kickback Statute (42 US SS 1320a-7b (b) Criminal penalties - Answer -Fines up to
$25,000/violation
Up to a 5-yr prison term/violation
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - Answer -False
Claims act liability
Civil monetary penalties and program exclusions
Potential $50,000 CMP/violation
Civil assessment of up to 3x amount of kickback
Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - Answer -Voluntary safe
harbors
Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - Answer -All
Federal Health Care Programs
The Stark Law (42 US SS 139nn) Prohibition - Answer -Prohibits a physician from
referring Medicare patients for designated health services to an entity with which the
physician (or immediate family member) has a financial relationship, unless an
exception applies)
Prohibits the designated health services entity from submitting claims to Medicare for
those services resulting from a prohibited referral
The Stark Law (42 US SS 139nn) Referrals - Answer -Referrals from a physician
,The Stark Law (42 US SS 139nn) (Items/Services) - Answer -Designated health
services
The Stark Law (42 US SS 139nn) (Intent) - Answer -No intent standard for
overpayment (strict liability)
Intent required for civil monetary penalties for knowing violations
The Stark Law (42 US SS 139nn) (Civil Penalties) only - Answer -Overpayment/refund
obligation
False Claims Act liability
Civil monetary penalties and program exclusion for knowing violations
Potential $15,000 CMP for each service
Civil assessment of up to 3x the amount claimed.
The Stark Law (42 US SS 139nn) (Exceptions) - Answer -Mandatory exceptions
The Stark Law (42 US SS 139nn) applies to - Answer -Medicare and Medicaid
(No commercial or tricare)
MACs: - Answer -Medicare Administrative Contractors
They analyze claims to determine provider compliance with Medicare coverage, coding,
and billing rules and take appropriate corrective action when providers are found to be
non-compliant.
The goal of Mac administrative actions - Answer -To correct the behavior in need of
change and prevent future inappropriate billing
The priority of MACs - Answer -To minimize potential future losses to the Medicare
Trust Fund through targeted claims review while using resource efficiently and treating
providers and beneficiaries fairly.
For repeated infractions, MACs have - Answer -The discretion to initiate progressively
more severe administrative action, commensurate with the seriousness of the identified
problem. (See Program Integrity Manual (PIM) chapter 3, SS3. 7.1)
Medicare Fee For Service Recovery Audit Program - Answer -Legislative mandated
program (Tax Relief and Health Care act of 2006)
, Utilizes Recovery Auditors to identify improper payments paid by Medicare to fee-for-
service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return underpayment.s.
MACs targeted provider-specific prepayment review - Answer -The MACs shall initiate
a targeted provider-specific prepayment review only when there is the likelihood of
sustained or high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review to prevent improper
payments for services identified by C ERT or Recovery Auditors as problem areas, as
well as, problem areas identified by their own data analysis
Cert Contractors and reviews - Answer -Because the Cert Contractors select claims on
a random basis, they are not required to notify providers of their intention to begin a
review.
Prepayment Review Time Frames: - Answer -When requesting documentation for
prepayment reviews, the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the request.
The reviewer shall Not grant extensions to providers who need more time to comply
with the request.
Reviewers shall deny claims for which the requested documentation was not received
by day 46.
Postpayment Review Time Frames - Answer -When requesting documentation for
postpayment review, the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the request.
ZPIC shall notify providers that requested documents are to be submitted with in 30-
calendar days of the request.
Additional Documentation Requests - Answer -If information is requested from both the
billing provider or supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - Answer -Prohibits offering,
paying, soliciting or reviving anything of value to induce or reward referrals or generate
Federal health care program business
Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - Answer -Referrals from
anyone
Anti-Kickback Statute (42 US SS 1320a-7b (b) - Answer -Any items or services
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Intent) - Answer -Intent MUST be
proven (knowing and willful)
Anti-Kickback Statute (42 US SS 1320a-7b (b) Criminal penalties - Answer -Fines up to
$25,000/violation
Up to a 5-yr prison term/violation
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - Answer -False
Claims act liability
Civil monetary penalties and program exclusions
Potential $50,000 CMP/violation
Civil assessment of up to 3x amount of kickback
Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - Answer -Voluntary safe
harbors
Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - Answer -All
Federal Health Care Programs
The Stark Law (42 US SS 139nn) Prohibition - Answer -Prohibits a physician from
referring Medicare patients for designated health services to an entity with which the
physician (or immediate family member) has a financial relationship, unless an
exception applies)
Prohibits the designated health services entity from submitting claims to Medicare for
those services resulting from a prohibited referral
The Stark Law (42 US SS 139nn) Referrals - Answer -Referrals from a physician
,The Stark Law (42 US SS 139nn) (Items/Services) - Answer -Designated health
services
The Stark Law (42 US SS 139nn) (Intent) - Answer -No intent standard for
overpayment (strict liability)
Intent required for civil monetary penalties for knowing violations
The Stark Law (42 US SS 139nn) (Civil Penalties) only - Answer -Overpayment/refund
obligation
False Claims Act liability
Civil monetary penalties and program exclusion for knowing violations
Potential $15,000 CMP for each service
Civil assessment of up to 3x the amount claimed.
The Stark Law (42 US SS 139nn) (Exceptions) - Answer -Mandatory exceptions
The Stark Law (42 US SS 139nn) applies to - Answer -Medicare and Medicaid
(No commercial or tricare)
MACs: - Answer -Medicare Administrative Contractors
They analyze claims to determine provider compliance with Medicare coverage, coding,
and billing rules and take appropriate corrective action when providers are found to be
non-compliant.
The goal of Mac administrative actions - Answer -To correct the behavior in need of
change and prevent future inappropriate billing
The priority of MACs - Answer -To minimize potential future losses to the Medicare
Trust Fund through targeted claims review while using resource efficiently and treating
providers and beneficiaries fairly.
For repeated infractions, MACs have - Answer -The discretion to initiate progressively
more severe administrative action, commensurate with the seriousness of the identified
problem. (See Program Integrity Manual (PIM) chapter 3, SS3. 7.1)
Medicare Fee For Service Recovery Audit Program - Answer -Legislative mandated
program (Tax Relief and Health Care act of 2006)
, Utilizes Recovery Auditors to identify improper payments paid by Medicare to fee-for-
service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return underpayment.s.
MACs targeted provider-specific prepayment review - Answer -The MACs shall initiate
a targeted provider-specific prepayment review only when there is the likelihood of
sustained or high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review to prevent improper
payments for services identified by C ERT or Recovery Auditors as problem areas, as
well as, problem areas identified by their own data analysis
Cert Contractors and reviews - Answer -Because the Cert Contractors select claims on
a random basis, they are not required to notify providers of their intention to begin a
review.
Prepayment Review Time Frames: - Answer -When requesting documentation for
prepayment reviews, the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the request.
The reviewer shall Not grant extensions to providers who need more time to comply
with the request.
Reviewers shall deny claims for which the requested documentation was not received
by day 46.
Postpayment Review Time Frames - Answer -When requesting documentation for
postpayment review, the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the request.
ZPIC shall notify providers that requested documents are to be submitted with in 30-
calendar days of the request.
Additional Documentation Requests - Answer -If information is requested from both the
billing provider or supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
