Healthcare Fraud and Abuse Flashcards
7 cards from real CHC 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 physician self-refers a patient to a physical therapy center in which the physician has an ownership interest. Under the Stark Law, which of the following must be true for this to be lawful?
Answer: The arrangement must fit within a recognized Stark Law exception
Stark Law prohibits self-referrals to DHS entities unless the arrangement meets a specific statutory or regulatory exception.
Which of the following best describes 'phantom billing' in healthcare fraud?
Answer: Billing for services that were never provided to the patient
Phantom billing refers to submitting claims for services, procedures, or supplies that were never actually provided to the patient.
Which statute allows a private citizen (relator) to file a lawsuit on behalf of the U.S. government against a person who has submitted false claims?
Answer: The False Claims Act (qui tam provisions)
The FCA's qui tam provisions allow private whistleblowers (relators) to bring lawsuits on the government's behalf and share in any recovery.
A home health agency provides free housekeeping services to patients who agree to use the agency for Medicare-covered skilled nursing services. This arrangement most likely violates:
Answer: Both the Anti-Kickback Statute and the False Claims Act
Providing free services (housekeeping) as an inducement to choose the agency for Medicare services violates the AKS, and any resulting Medicare claims would be false claims under the FCA.
Under the Civil Monetary Penalties Law (CMPL), which of the following conduct can result in exclusion from federal healthcare programs?
Answer: Employing or contracting with an excluded individual
The CMPL imposes penalties and potential exclusion on entities that employ or contract with individuals or entities excluded from federal healthcare programs.
Which of the following is a key difference between civil and criminal liability under the False Claims Act?
Answer: Criminal FCA can result in imprisonment, while civil FCA results in monetary penalties and treble damages
Criminal FCA convictions can result in fines and up to 10 years imprisonment, while civil FCA liability results in per-claim penalties plus treble the damages sustained by the government.
A lab bills Medicare for a comprehensive metabolic panel (CPT 80053) but only performs a basic metabolic panel (CPT 80048). This is an example of:
Answer: Upcoding
Upcoding occurs when a provider bills for a higher-level or more expensive service than was actually performed, as in billing for a comprehensive panel when only a basic panel was run.