Lec 10: Part 2: Fraud and Abuse

Question 1

What are some causes of improper payment?

Answer 1

1) Given funds you did not deserve
2) Poor documentation
3) Incorrect coding
4) Not justifying services

Question 2

If you are a good PT, and do not have time to document, is this okay?

Answer 2

NO - you must justify what you billed in your documentation, especially if you get audited, this is important

Question 3

How does the fraud prevention system work: Is everyone an equal target for audits?

Answer 3

NO

Question 4

How does the fraud prevention system work: Who do they target?

Answer 4

New providers; concept profiling if you are overcharging in comparison to other PTs in the area

Question 5

How does the fraud prevention system work: Data is _______ because there is a ____ of data out there. They will target the _______

Answer 5

Analyzed
Pool
Outliers

Question 6

Purposely billing for services that were not provided or were not medically necessary, billing for a higher level of service than what was provided, misreporting costs or other data to increase payments, paying or receiving kickbacks, illegally marketing products, and/or stealing providers’ or beneficiaries’ identities is what?

Answer 6

FRAUD

Question 7

Fraud or abuse? Which one is done with intent?

Answer 7

Fraud

Evidence that you knew you were doing something wrong

Question 8

Billing dead people is what?

Answer 8

Fraud

Question 9

What is this: Practices that either directly or indirectly result in unnecessary costs to Medicare or Medicaid, including misuse of codes on a claim, charging excessively for services or supplies, and billing for services that were not medically necessary

Answer 9

Abuse

Question 10

Fraud of abuse: is an inadvertent mistake?

Answer 10

Abuse

Question 11

Civil liability for knowingly submitting or causing to be submitted a false or fraudulent claim to the federal government (documenting something when you did not do it, omitting information, not supporting claims)

Answer 11

False Claims Act

Question 12

Qui tam actions are in what?

Answer 12

False Claims Act

Question 13

Criminal offense to knowingly and willfully offer, pay, solicit, or receive remuneration or induce or reward referrals of items or services reimbursable by a Federal healthcare program (cannot pay a provider for referrals)

Answer 13

Anti-kickback statute

Question 14

This involves safe harbor regulations

Answer 14

Anti-kickback statute

Question 15

Prohibits referral for health services to an entity in which the physician (or member of immediate family) has ownership/investment interest or a compensation arrangement (exceptions apply)

Answer 15

Physician Self-Referral Law (Stark)

Question 16

For physicians, they cannot profit from a business that they refer to. This is what?

Answer 16

Physician Self-Referral Law (Stark)

Question 17

Prohibits knowingly and willfully executing or attempting to execute a scheme or artifice to defraud a healthcare benefit program, or to obtain (by false or fraudulent pretenses) any of the money or property owned by or in the custody of the healthcare program

Answer 17

Criminal health care fraud statute

Question 18

This provision was extended by ACA to protect against retaliation

Answer 18

Whistleblower Statute

Question 19

What are general penalties for violating anti-fraud laws/statutes?

Answer 19

Fines
Prison
Exclusion from federal programs

Question 20

Healthcare organizations establish ___________ that set up standards to conform to local, state, and federal laws and regulations

Answer 20

Compliance programs

Question 21

Compliance programs enable providers and employers to reduce exposure to penalties and sanctions, and as a result improve______ and______ of services

Answer 21

Efficiency and quality

Question 22

Compliance programs are based on the type of ______ or ______

Answer 22

Provider or organization

Question 23

The OIG and DHHS have coding and billing guidelines for:

Answer 23

Hospitals
Clinical labs
Physician and therapist offices
Home care organizations
SNF
Hospices

Question 24

What are the benefits: Fulfill legal duty to ensure that _____ or _____ claims for payment for services are not being submitted to government or private reimbursement sources

Answer 24

False or inaccurate

Question 25

What are the benefits: Opportunity to _____ and prevent illegal and unethical activity early

Answer 25

Identify

Question 26

What are the benefits: Concretely demonstrate to employees and the community the company’s commitment to ________

Answer 26

Honest conduct

Question 27

What are the benefits: Create a ______ that allows employees to report real or potential problems

Answer 27

Methodology

Question 28

What are the benefits: Develop policies and procedures to allow prompt thorough investigations of allegations of ______

Answer 28

Misconduct

Question 29

What are the benefits: Reduce the organization’s exposure to ______ damages, _____ sanctions, and administrative ________

Answer 29

Civil Criminal Overpayments

Question 30

What are the benefits: Discourage employee _____ or _______ actions

Answer 30

Qui tam | Whistleblower

Question 31

What are the benefits: Allow for decisive and appropriate_______ actions

Answer 31

Corrective

Question 32

Some of the top compliance uses in PT:

Answer 32

1. Services not medically necessary 2. Services not provided or documented 3. Unbundling or up-coding 4. Time documentation inconsistent with service billed 5. Inappropriate personnel 6. Provider ID numbers misused 7. Care below accepted standard 8. Waving of co-pays of deductibles

Question 33

Types of Medicare/Medicaid fraud and abuse violations: Providing and billing for PT services without a _______ and/or without the appropriate _______ of a physician or licensed PT as required by federal and state law

Answer 33

PT License | Supervision

Question 34

Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services when the service performed was ______ and did not constitute PT

Answer 34

Unskilled

Question 35

Types of Medicare/Medicaid fraud and abuse violations: Billing for PT services that were ________, only partially _______, or not medically necessary

Answer 35

Never performed | Performed

Question 36

Types of Medicare/Medicaid fraud and abuse violations: Licensee, knowingly or unknowingly, billing the _______ for treatment

Answer 36

Incorrect code

Question 37

Why is so much effort invested in program integrity?

Answer 37

Paying for the right things

Question 38

Who can deliver PT services that can be billed under Medicare?

Answer 38

Physicians PTs PTAs NPPs

Question 39

Billing incident-to means: (3)

Answer 39

1. Billing for each therapy visit or incident 2. Billing for physician services when service was provided by unlicensed therapist 3. These services relate to services furnished as an integral, although incidental, part of the physician’s personal professional services in the course of Dx or treatment of an injury or illness. A licensed HCP such as a PT may provide the required services under the physician’s direct supervision, and these services are billed by the physician.

Question 40

What types of payment for referrals is acceptable under Medicare?

Answer 40

Equitable, sharing of profits that come out of a patient care in a business?

Question 41

What is a corporate integrity agreement?

Answer 41

This is your settlement

Question 42

What is the look back period for Medicare Recovery Audit Contractors?

Answer 42

3 years