CCT Healthcare Fraud and Abuse 2 — Questions and Answers
Question 1: Which federal statute prohibits offering, paying, soliciting, or receiving anything of value to induce referrals of items or services covered by federal healthcare programs?
- False Claims Act
- Anti-Kickback Statute (Correct answer)
- Stark Law
- HIPAA Privacy Rule
Correct answer: Anti-Kickback Statute
The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive remuneration to induce referrals covered by federal healthcare programs.
Question 2: A hospital gives physicians free office space below fair market value in exchange for referrals. This arrangement most likely violates which law?
- EMTALA
- Stark Law (Correct answer)
- ERISA
- Bayh-Dole Act
Correct answer: Stark Law
Stark Law (42 U.S.C. § 1395nn) prohibits physicians from referring Medicare/Medicaid patients for designated health services to entities with which the physician has a financial relationship, including below-market rent.
Question 3: What is 'upcoding' in the context of healthcare fraud?
- Using outdated billing codes
- Billing for a more expensive service than was actually provided (Correct answer)
- Submitting duplicate claims
- Failing to document services rendered
Correct answer: Billing for a more expensive service than was actually provided
Upcoding occurs when a provider submits a billing code for a higher-level or more expensive service than was actually provided, resulting in inflated reimbursement.
Question 4: Under the False Claims Act, what is the penalty range per false claim submitted to the government?
- $1,000–$5,000
- $5,000–$10,000
- $13,946–$27,894 (adjusted for inflation) (Correct answer)
- $50,000–$100,000
Correct answer: $13,946–$27,894 (adjusted for inflation)
FCA civil penalties are inflation-adjusted; as of recent updates, penalties range from approximately $13,946 to $27,894 per false claim, plus treble damages.
Question 5: Which exclusion authority allows the OIG to exclude individuals or entities convicted of program-related crimes from participation in federal healthcare programs?
- Mandatory exclusion under 42 U.S.C. § 1320a-7(a) (Correct answer)
- Permissive exclusion under 42 U.S.C. § 1320a-7(b)
- Civil Monetary Penalties Law
- Corporate Integrity Agreement
Correct answer: Mandatory exclusion under 42 U.S.C. § 1320a-7(a)
Mandatory exclusion under 42 U.S.C. § 1320a-7(a) requires the OIG to exclude individuals convicted of Medicare/Medicaid fraud, patient abuse, or felony drug offenses for a minimum of five years.
Question 6: A compliance officer discovers that a physician has been receiving free sports tickets from a medical device vendor. Under the Anti-Kickback Statute, this arrangement is best described as:
- A de minimis exception that requires no action
- Potential remuneration that could trigger AKS liability (Correct answer)
- Permissible under the personal services safe harbor
- Compliant if disclosed to the hospital
Correct answer: Potential remuneration that could trigger AKS liability
Anything of value — including entertainment like sports tickets — can constitute remuneration under the AKS if it is intended to induce or reward referrals, regardless of amount.
Question 7: Which program allows states to bring fraud and abuse actions against Medicaid providers under the authority of the Social Security Act?
- Medicaid Fraud Control Units (MFCUs) (Correct answer)
- State Attorney General Civil Division
- Medicaid Integrity Program
- Federal Bureau of Investigation Healthcare Fraud Unit
Correct answer: Medicaid Fraud Control Units (MFCUs)
Medicaid Fraud Control Units (MFCUs) are state agencies that investigate and prosecute Medicaid provider fraud and patient abuse, operating under federal oversight and receiving 75% federal funding.
CCT Healthcare Fraud and Abuse 2
Which federal statute prohibits offering, paying, soliciting, or receiving anything of value to induce referrals of items or services covered by federal healthcare programs?