CHC Healthcare Fraud and Abuse 3 — Questions and Answers
Question 1: 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?
- The physician must disclose the relationship to the patient only
- The arrangement must fit within a recognized Stark Law exception (Correct answer)
- The physical therapy center must be accredited by a national body
- The referral must be approved by the hospital's medical staff
Correct 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.
Question 2: Which of the following best describes 'phantom billing' in healthcare fraud?
- Billing for a more expensive procedure than performed
- Billing for services that were never provided to the patient (Correct answer)
- Billing separately for procedures that should be bundled
- Billing for a non-covered service using a covered service code
Correct 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.
Question 3: 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?
- The Stark Law
- The Anti-Kickback Statute
- The False Claims Act (qui tam provisions) (Correct answer)
- The Civil Monetary Penalties Law
Correct 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.
Question 4: 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:
- The Stark Law only
- The Anti-Kickback Statute only
- Both the Anti-Kickback Statute and the False Claims Act (Correct answer)
- HIPAA and the Stark Law
Correct 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.
Question 5: Under the Civil Monetary Penalties Law (CMPL), which of the following conduct can result in exclusion from federal healthcare programs?
- Employing or contracting with an excluded individual (Correct answer)
- Failing to conduct annual compliance training
- Not updating a provider enrollment record within 30 days
- Billing a commercial payer for uncovered services
Correct 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.
Question 6: Which of the following is a key difference between civil and criminal liability under the False Claims Act?
- Criminal FCA requires proof of actual monetary loss to the government
- Civil FCA requires proof of specific intent to defraud, while criminal does not
- Criminal FCA can result in imprisonment, while civil FCA results in monetary penalties and treble damages (Correct answer)
- Civil FCA applies only to healthcare, while criminal FCA applies to all industries
Correct 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.
Question 7: 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:
- Unbundling
- Upcoding (Correct answer)
- Duplicate billing
- Balance billing
Correct 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.
CHC Healthcare Fraud and Abuse 3
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?