Deck 16: Health Care Regulation and Compliance

Question 1

Which of the following is the primary criminal law for dealing with fraud and abuse?

A) False Claims Act
B) Stark Law
C) Civil monetary penalties
D) Anti-Kickback Statute

Answer 1

D

Question 2

Which of the following is an example of a Stark Law violation?

A) A hospital offering a physician office space at unfair market value
B) Paying a physician for a referral
C) Hiring a doctor who is an excluded party as a Medicare Provider
D) Upcoding a claim to receive higher reimbursement
E) All of these are correct.

Answer 2

B

Question 3

Violations of the Emergency Medical Treatment and Active Labor Act (EMTALA) include all of the following, except:

A) dumping a patient on another hospital because they are very sick.
B) diverting a patient to another hospital because they are unable to pay for services.
C) completing a medical screening exam and stabilizing the patient.
D) refusing to treat a patient because their benefits are better at a different hospital.
E) All of these are violations of EMTALA.

Answer 3

C

Question 4

Essential elements of an effective compliance program include which of the following?

A) Establishing compliance standards of conduct and procedures
B) Overall compliance program oversight
C) Due care in delegation of authority
D) Monitoring and auditing systems
E) All of these are correct.

Question 5

Regulations under the Anti-Kickback Statute and Stark Law:

A) have both been revoked recently.
B) will probably be amended soon.
C) are being combined into one law because they are so similar.
D) are being shifted to state jurisdiction because the federal government does not want to investigate these any more.
E) None of these is correct.

Question 6

Which of the following statements about EMTALA is correct?

A) Requires only hospitals that receive payments from Medicare or Medicaid provide an appropriate medical screening exam
B) Requires that any facility with a dedicated emergency department provides patients with an appropriate medical screening exam
C) Requires only private, for-profit hospitals provide patients an appropriate medical screening exam
D) Mandates that no patient should be billed for services if they cannot pay

Question 7

Compliance internal controls include which of the following?

A) Presidential overview
B) Monitoring to assess the quality of the system
C) Risk assessment
D) Public policy
E) Monitoring to assess the quality of the system and public policy
F) Monitoring to assess the quality of the system and risk assessment

Question 8

Fraud is an improper act that is unintentional and inconsistent with standard practices.

Question 9

Under qui tam rules, the whistleblower can be awarded a percentage of the monies recovered.

Question 10

The Stark Law was implemented to prohibit physicians from referring patients to providers where the physicians may have a financial interest.

Question 11

The Sherman Anti-Trust Act prohibits mergers and acquisitions that lessen competition.

Question 12

A successful compliance plan requires buy-in from upper management

Question 13

Recovery Audit Contractors analyze claims before they are paid to identify fraud and abuse before it happens.

Question 14

Physicians can be prosecuted under the Stark Law or the Anti-Kickback Statute, but not both.

Question 15

Define the following terms:
• Abuse
• Anti-Kickback Statute (AKS)
• Fraud
• Qui tam relator
• Recovery Audit Contractors (RAC)
• Health Care Fraud Prevention and Enforcement Action Team (HEAT)
• The False Claims Act (FCA)
• Stark Law
• Emergency Medical Treatment and Active Labor Act (EMTALA)
• Sherman Antitrust Act

Question 16

You are an employee of Big Hands Home Health Agency and are responsible for assigning RNs, LPNs, and CNAs, to go out to homes to care for clients. The owner of the agency, Lotta Gamble, is rarely around because she is out "scouting business." In reality, she takes a lot of cruises, which she posts about on Instagram and Facebook and brags about all the gambling she does in international waters.
One day, you receive a call from an elderly woman's daughter. "My mother says she hasn't seen any one from Big Hands in a month-but she received bills for a daily RN visit." You tell the woman that your boss is out of town, but as soon as she returns, you will let her know and get back to them. A few days later, you receive a similar call from another family. And then another and another. You are starting to see a pattern. Since the boss has taken her computer with her, you have no way to follow up. It will have to wait.
When your boss returns from her latest Caribbean cruise, all tanned and rested, you brief her on the assignments and employee issues. You then say, "And, we received calls from several families saying they were billed for services they didn't receive. I told them I would investigate and get back to them. I'm guessing this is just a case of typing in the wrong numbers?" You hope.
Your boss says in a low voice, "Have you mentioned this to anyone else?"
You shake your head. "No, I waited to talk to you."
"Good girl. I knew I could count on you." She reaches into her purse. "I had a good streak on the backgammon tables. Here's a five-hundred-dollar bonus for you. Let's keep this little matter to ourselves, shall we?"
Those who commit crimes, including healthcare fraud and abuse, require need three things: motive/desire, opportunity/means, and victims/patients. Motives to commit fraud and abuse include, but are not limited to: jealousy, greed, anger, financial difficulties, feeling underappreciated, and, the thrill of a challenge.
1. What motives do you see in this case?
2. What opportunities/means do you see in this case?
3. Who are the victims of this fraud and abuse?
4. What laws might Lotta Gamble be violating?
5. Are the patients violating any laws or are they victims?
6. What regulatory agencies have jurisdiction over this matter?
7. Who should investigate this home health agency?
8. What are the potential penalties for Lotta?
9. If you take the $500 bonus and remain quiet, have you committed a crime?
10. Should you report this? If so, who should you call? What evidence do you have?
11. Should you be updating your resume and looking for a new job?
Support your responses with scholarly articles and rationales.