Final Exam - Hsa 2182

Front 1

Define fraud

Back 1

Is an intentional act of deception

Front 2

Define abuse

Back 2

Consists of improper acts that are unintentional but inconsistent with standard practices.

Front 3

Common forms of fraud and abuse

Back 3

The more common forms of fraud and abuse are providers billing for services that were not provided or did not meet medical necessity criteria (false claims), submitting duplicate bills, up-coding services to receive higher reimbursement, and receiving kickbacks from referrals.

Front 4

Elements of Operation Restore Trust (ORT)

Back 4

Started in 1995 to counter charges about healthcare fraud and abuse. The program not only investigates and applies penalties for fraud, but also provides advisories to prevent violations. It uses statistical data to select claims for audits and investigations. Department of Health and Human Service (DHHS) monitors the activities overt ORT

Front 5

EMTALA law and its requirements

Back 5

Enacted in 1986. Act To prevent patient dumping. It is also known as the Ant-Dumping Act. It is used to prevent emergency rooms from refusing treatment or transferring a patient to another facility because of the patient’s inability to pay for treatment.

It requires (mandates) that an appropriate medical screening exam (MSE) be given to any patient who present to any department that is established as a provider of emergent or urgent care. If an MSE is performed and shows that an emergency condition exists, the patient must either be treated and discharged or admitted as an inpatient and transferred from the dedicated emergency department.

Front 6

Criminal Disclosure Provisions of the Social Security Act

Back 6

Makes it a felony for a healthcare provider or beneficiary to possess “knowledge of the occurrence of any event affecting his initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either a greater amount or quantity that is due of when no such benefit or payment is authorized. May include punishment of up to 5 years in prison and/o fines of up to $25,000. Imposes a requirement to disclose over-payments to the government regardless of intent at the time the claim was submitted.

Front 7

Three Antitrust Acts / primary function

Back 7

1. Sherman Antitrust Act – Applies to an agreements that unreasonably restrain trade. These include, but are not limited to: price fixing, boycotting other organizations, dividing market territories, and using coercive tactics with the intent to harm or injure another party.
2. Clayton Act – Prohibits mergers and acquisitions that may lessen competition. Unlike the Sherman Act, the Clayton Act only imposes civil penalties.
3. Federal Trade Commission Act – Prohibits unfair methods of competition. This may include techniques such as larger businesses using their size to gain lower prices from suppliers and suppliers giving discounts to larger companies, without providing the same for smaller ones.

Front 8

OIG stance on corporate compliance and why

Back 8

The OIG strongly recommends the adoption of a corporate compliance plan as it helps limit the risk compliance errors an limits the liability of management and directors. Provides employees the guidelines necessary to follow the laws and allows management to know that the laws are being followed.

Front 9

Eight elements of Corporate Compliance Program
Elements
Written policies, procedures, and standards of conduct
Training and education
Effective lines of communication throughout the organization Sponsor must have:
a) organized lines of communication to effectively provide information as it pertains to compliance an issues.
b) mechanisms are in place for capturing concerns and risks

Enforcement procedures Must enforce standards through disciplinary guidelines
Procedures and effective internal monitoring and auditing. These requirements are as follows:
a) must have a monitoring and auditing programs
b) must monitor and audit contractors
c) must allow CMS to audit financial records.
d) must allow the federal government to perform on sit audits.
e) contractors must allow CMS access to their records.
Procedures for corrective action The organization must ensure:
a) prompt responses to violations
b) appropriate corrective action is taken

Fraud and abuse plan must be in place Must have a plan in place to detect and prevent fraud and abuse

Back 9

Eight elements of Corporate Compliance Program
Requirement
These must speak to the organization’s commitment to comply with all applicable federal and state standards.

Front 10

Eight elements of Corporate Compliance Program
Elements
Training and education

Back 10

Eight elements of Corporate Compliance Program
Requirement
Must have a training and education program in place.

Front 11

Eight elements of Corporate Compliance Program
Elements
Designation of a compliance officer Sponsor must have:

Back 11

Eight elements of Corporate Compliance Program
Requirement
Sponsor must have:
a) compliance officer in place
b) compliance committee in place
c) established protocol for overview
d) compliance officer if responsible for fraud and abuse program

Front 12

Eight elements of Corporate Compliance Program
Elements
Effective lines of communication throughout the organization

Back 12

Eight elements of Corporate Compliance Program
Requirement
Sponsor must have:
a) organized lines of communication to effectively provide information as it pertains to compliance an issues.
b) mechanisms are in place for capturing concerns and risks

Front 13

Eight elements of Corporate Compliance Program
Elements
Enforcement procedures

Back 13

Eight elements of Corporate Compliance Program
Requirement
Must enforce standards through disciplinary guidelines

Front 14

Eight elements of Corporate Compliance Program
Elements
Procedures and effective internal monitoring and auditing.

Back 14

Eight elements of Corporate Compliance Program
Requirement
These requirements are as follows:
a) must have a monitoring and auditing programs
b) must monitor and audit contractors
c) must allow CMS to audit financial records.
d) must allow the federal government to perform on sit audits.
e) contractors must allow CMS access to their records.

Front 15

Eight elements of Corporate Compliance Program
Elements
Procedures for corrective action

Back 15

Eight elements of Corporate Compliance Program
Requirement
The organization must ensure:
a) prompt responses to violations
b) appropriate corrective action is taken

Front 16

Eight elements of Corporate Compliance Program
Elements
Fraud and abuse plan must be in place

Back 16

Eight elements of Corporate Compliance Program
Requirement
Must have a plan in place to detect and prevent fraud and abuse