Deck 14: Health-Care Fraud and Abuse

Question 1

Which usually involves a qui tam action?

A)FCA claim
B)HIPAA violation
C)Negligent action
D)Stark laws

Answer 1

FCA claim

Question 2

The Deficit Reduction Act requires _____.

A)Actions of employees to be protected under nolo contendre so that the government is not a risk of being sued in a court of law
B)Compliance programs to shield hospitals from liability for unintentional fraud and abuse on the part of its employees
C)Facilities that receive more than $5 million in Medicaid reimbursement to have in place written policies and handbooks to educate staff
D)That only the entity may be prosecuted for fraud and abuse, exempting individual providers and other healthcare professionals

Answer 2

Facilities that receive more than $5 million in Medicaid reimbursement to have in place written policies and handbooks to educate staff

Question 3

A qui tam action is defined as _____.

A)Any action brought against a healthcare facility or provider by a third-party payer or third-party administrator
B)Government entity that sue on behalf of a private plaintiff to receive a portion of the recovered funds
C)Private plaintiffs who sue on behalf of the U.S.government and who receive a portion of the recovered funds
D)The prosecution of fraud and abuse, which results in governments receiving a portion of recovered funds

Answer 3

Private plaintiffs who sue on behalf of the U.S.government and who receive a portion of the recovered funds

Question 4

What are financial settlements or arrangements that specifies rules of conduct to be followed to remedy any fraud and abuse found plus any monitoring and reporting requirements?

A)Anti-kickback statutes
B)Corporate integrity agreements
C)Permissive/mandatory exclusions
D)Qui tam actions

Question 5

A chief compliance officer's duties might include which of the following?

A)education and training
B)complaints evaluation and resolution
C)audits and monitoring of compliance
D)all of the above

Question 6

Stark I and Stark II laws were passed because _____.

A)False misrepresentations of facts that are relied upon by another were a detriment to others and a departure from reasonable use
B)Increase federal scrutiny caused healthcare organizations to change their methods of operation, such as submitting false claims
C)Physicians were abusing the healthcare system by referring patients to services in which they (or family members) had a financial interest
D)Relators were suing on behalf of the U.S.government expressly to receive a portion of the recovered funds if the lawsuit was successful

Question 7

Compliance programs seek to _____.

A)Enhance health information management functions in organizations
B)Maximize reimbursement from federally funded healthcare programs
C)Prevent and detect conduct that does not conform to applicable laws
D)Punish healthcare providers who engage in illegal billing practices

Question 8

Which are examples of DHHS OIG programs implemented to educate entities about proper claims submission?

A)CCI
B)FCA
C)PHI
D)RICO

Question 9

In the context of billing fraud, which is associated with unbundling?

A)Accepting payment for healthcare services never provided to patients
B)Billing third-party payers (instead of patients) for noncovered services
C)Referring patients to a facility in which the physician has a financial interest
D)Separately billing laboratory tests to increase reimbursement from payers

Question 10

Which is the most common form of health care fraud and abuse?

A)Claims and billing practices
B)Clinical trial management
C)HMO contracts
D)Reporting of X-ray results

Question 11

Kickback violations occur when a(n) _____.

A)Physician refers patients to a facility in which he holds a financial interest
B)Provider receives compensation for patient referrals to a specific facility
C)Third-party payers reimburse facilities and physicians for overbilled services
D)Surgical procedure is coded at a higher level to increase financial compensation

Question 12

Which bars a provider from receiving Medicare reimbursement either permanently or for a prescribed period of time?

A)Civil monetary penalty process
B)Fraud and abuse violations
C)Permissive and mandatory exclusion
D)Stark I and Stark II legislation

Question 13

Which is the false misrepresentation of fact that is relied on by another to that person's detriment and is a departure from reasonable use?

A)Fraud and abuse
B)Insurance evasion
C)Legal malpractice
D)Malfeasance

Question 14

Anti-kickback statutes were enacted to prevent _____.

A)HMO control of health care
B)Overbilling of laboratory services
C)Plaintiffs from filing qui tam actions
D)Remuneration for patient referrals

Question 15

Which changed the nature of compliance programs for some institutions from voluntary to mandatory and provided a financial incentive for states to adopt laws similar to federal laws regarding fraud and abuse?

A)Deficit Reduction Act
B)False Claims Act
C)HIPAA
D)Stark I and Stark II

Question 16

In the context of billing fraud, upcoding is submitting a bill for a higher level of reimbursement than actually rendered in order to receive _____.

A)financial kickbacks from payers
B)higher reimbursement rates
C)provider referrals for compensation
D)Stark law monetary incentives

Question 17

A Stark violation occurs when _____.

A)Billers submit insurance claims twice for the same service to the patients
B)Financial payment for patient referrals is requested from healthcare facilities
C)Insurance payments for patient services that were not provided are processed
D)Providers refer patients to a facility in which the provider holds a financial interest

Question 18

An ethics-based compliance program conforms to applicable laws through _____ because it is the right thing to do or because a cost-benefit analysis reveals it would be a sound business practice.

A)Efforts to avoid punishment if found guilty of violating standards
B)Law enforcement and prosecution of those suspected of wrongdoing
C)Mandatorily imposed accreditation standards and policies/procedures
D)Voluntary compliance with local, state and federal laws and regulations

Question 19

Civil money penalty law may be applied to a violation, such as _____.

A)Banning a provider from receiving further reimbursement by government funded health programs
B)Limiting the fine that can be imposed to five times the amount of damages, up to a total of $20,000
C)Protecting providers from being required to remunerate patients and third-party payers for violations
D)Recovering money damages for false or fraudulent claims requiring the provider to make restitution

Question 20

The DHHS Office of the Inspector General (OIG) is _____.

A)Authorized to conduct civil and criminal investigations of fraud associated with Medicare
B)Not allowed to guide healthcare providers on how to comply with applicable laws and regulations
C)Permitted to investigate claims of fraud and abuse and prohibited from investigating overpayments
D)Simply a figurehead office that wields little or no effect on healthcare fraud and abuse violations

Question 21

Which program specifically directs the DHHS to enter into agreements with private companies to carry out fraud and abuse protections?

A)Beneficiary Incentive Program
B)Fraud and Abuse Control Program
C)Healthcare Fraud and Abuse Data Collection Program
D)Medicare Integrity Program

Question 22

According to the AMA, it is ethical for a physician to hold a financial interest in a health care facility when the physician's _____.

A)Arrangement with payers results in payment to patients
B)Facility is the only one available in the immediate region
C)Financial interest is disclosed to those referred for services
D)Patients are insured so payment for services is guaranteed

Question 23

When employees have password access to medical records, _____.

A)Employee have a responsibility to allow the truth to be shared with the public
B)It is acceptable to review a celebrity's chart because of their implied consent
C)Released information is limited to that which has been authorized by the patient
D)The employer has implied that employees have control over release of records

Question 24

Which government agency's authority extends beyond the jurisdiction of other government programs?

A)DCIS
B)FBI
C)FCA
D)OIG

Question 25

The Center for Medicare and Medicaid Services PEPP program _____.

A)Automates audits to reduce intentional fraud
B)Clarifies DHHS OIG regulations
C)Promotes the national correct coding initiative
D)Reduces Medicare payment error rates

Question 26

The primary responsibility for investigating claims of fraud committed against the military's health insurance programs is the responsibility of the _____.

A)Centers for Medicare and Medicaid Services
B)Defense Criminal Investigative Service
C)DHHS Office of the Inspector General
D)Office of the Surgeon General

Question 27

During the investigation of allegations of suspected fraud and abuse, when a government agent presents with a search warrant for patient records, the health information manager _____.

A)Collects all records and answers any additional questions asked by the agent
B)Has a duty to cooperate with the agent and must notify facility legal counsel
C)Is prohibited from notifying legal counsel if also served with a court order
D)Rejects the advice of legal counsel if the government agent instructs as such

Question 28

Assigning diagnostic and procedural codes to obtain better reimbursement alone is _____.

A)Helpful
B)Necessary
C)Permitted
D)Unethical