Healthcare Fraud and Abuse Flashcards
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Read the first 7 Healthcare Fraud and Abuse flashcards as text
Which federal statute prohibits offering, paying, soliciting, or receiving anything of value to induce referrals of items or services covered by federal healthcare programs?
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.
A hospital gives physicians free office space below fair market value in exchange for referrals. This arrangement most likely violates which law?
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.
What is 'upcoding' in the context of healthcare fraud?
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.
Under the False Claims Act, what is the penalty range per false claim submitted to the government?
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.
Which exclusion authority allows the OIG to exclude individuals or entities convicted of program-related crimes from participation in federal healthcare programs?
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.
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:
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.
Which program allows states to bring fraud and abuse actions against Medicaid providers under the authority of the Social Security Act?
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.