Healthcare Fraud and Abuse Flashcards
7 cards from real CCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Fraud and Abuse flashcards as text
A Corporate Integrity Agreement (CIA) is typically entered into between a healthcare provider and which government agency?
Answer: Office of Inspector General (OIG)
CIAs are negotiated between healthcare providers and the OIG as part of civil settlement agreements, requiring the provider to implement compliance measures in exchange for continued program participation.
Under the Exclusion Statute, what is the minimum mandatory exclusion period for an individual convicted of a felony related to Medicare or Medicaid fraud?
Answer: 5 years
42 U.S.C. § 1320a-7(a) requires a minimum 5-year mandatory exclusion for individuals convicted of program-related crimes, patient abuse, or felony drug offenses.
Which element distinguishes 'fraud' from 'abuse' in federal healthcare program enforcement?
Answer: Intentional deception or misrepresentation versus inadvertent billing errors
Healthcare fraud requires intentional deception or misrepresentation to obtain unauthorized benefits, while abuse involves practices that are inconsistent with sound business or medical practices but may lack criminal intent.
The Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created to:
Answer: Coordinate joint DOJ and HHS efforts to combat Medicare and Medicaid fraud
HEAT is a joint initiative between the DOJ and HHS that coordinates federal efforts to prevent fraud, waste, and abuse in Medicare and Medicaid through Strike Force teams and data analytics.
A physician refers patients exclusively to a lab in which he owns a 15% equity stake. Under Stark Law, this arrangement:
Answer: Triggers the self-referral prohibition regardless of ownership percentage
Stark Law prohibits referrals to entities in which the physician (or immediate family) has any financial relationship, including any ownership interest, without a qualifying exception.
What is the primary purpose of the OIG's Work Plan?
Answer: To identify OIG audit and investigation priorities for the healthcare industry
The OIG Work Plan outlines the audits, evaluations, and investigations the OIG plans to undertake during the year, helping providers identify areas of heightened scrutiny.
Which type of Medicare fraud scheme involves a provider billing for a more expensive brand-name drug while dispensing a less expensive generic?
Answer: Prescription drug substitution fraud
Prescription drug substitution fraud occurs when a pharmacist or provider bills for a higher-cost drug but dispenses a cheaper substitute, pocketing the reimbursement difference.