HealthStream Regulatory Script. Corporate Compliance: A Proactive Stance. Version: [February 2007]

Transcription

1 HealthStream Regulatory Script Corporate Compliance: A Proactive Stance Version: [February 2007] Lesson 1: Introduction Lesson 2: Importance of Compliance & Compliance Programs Lesson 3: Laws and Regulations Lesson 4: Elements of a Compliance Program

2 Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on corporate compliance (link to glossary) programs. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines. FLASH ANIMATION: 1001.SWF/FLA Animation with the following words/phrases flying toward center of animation area: HIPAA EMTALA Medicare Office of the Inspector General Health and Human Services Duplicate billing Coding Creep Upcoding Unbundling When they collide, the phrase Corporate Compliance emerges from the center area of the animation. Page 1 of 4 2

3 1002 Course Rationale The purpose of a compliance program is to reduce the risk of misconduct [glossary] in your facility. IMAGE: 1002.JPG This course will teach you how to do your part to: Support the compliance program Reduce the risk of misconduct You will learn about: The consequences of misconduct The laws and regulations that healthcare facilities must follow How a compliance program works Page 2 of 4

4 1003 Course Goals After completing this course, you should be able to: Recognize the benefits of a compliance program. List key laws and regulations for the healthcare industry. Recognize the features of each law and the penalties for violating each. List the parts of an effective compliance program. Recognize the role of each part. NO IMAGE Page 3 of 4

5 1004 Course Outline This introductory lesson gives the course rationale, goals, and outline. FLASH ANIMATION: 1004.SWF/FLA Lesson 2 talks about why a compliance program is important. Lesson 3 describes key healthcare industry laws and regulations. This includes the penalties for noncompliance [glossary]. Finally, lesson 4 explains the parts of an effective compliance program. This includes how you can use the program to do your job legally and ethically [glossary]. Page 4 of 4

6 Lesson 2: Importance of Compliance & Compliance Programs 2001 Introduction & Objectives Welcome to the lesson on the importance of compliance and compliance programs. FLASH ANIMATION: 2001.SWF/FLA After completing this lesson, you should be able to: Identify possible consequences of noncompliance. Recognize the benefits of a compliance program. Page 1 of 9

7 2002 Heightened Emphasis on Healthcare Fraud In recent years, government agencies have started to look more closely for healthcare fraud and misconduct. IMAGE: 2002.GIF A lot of federal money has been used to investigate and prosecute suspected fraud. This has increased the number of providers convicted of fraud. Page 2 of 9

8 2003 Consequences of Misconduct When a provider is convicted of fraud, penalties can include: Criminal fines Civil damages Jail time Exclusion from Medicare or other government programs FLASH ANIMATION: 2003.SWF/FLA In addition, a conviction can lead to serious public relations harm. Page 3 of 9

9 2004 Compliance Programs To help prevent misconduct, healthcare facilities have corporate compliance programs. A good compliance program reduces the risk of error or fraud. IMAGE: 2004.JPG It does so by giving guidelines for how to do your job in an ethical and legal way. All of the following jobs are covered in the plan: Facility administration Clinical staff Non-clinical staff Vendors Page 4 of 9

10 2005 Benefits of a Compliance Program Remember: A compliance program helps to prevent: Fraud Abuse Waste IMAGE: 2005.JPG This helps to meet some of the most basic goals of healthcare: To provide quality patient care To keep healthcare costs low To improve the way that healthcare providers do their jobs Page 5 of 9

11 2006 Benefits of a Compliance Program In addition, an effective compliance program helps your facility: Do its legal duty not to submit wrong claims to federal programs. Show that it cares about ethical and legal conduct. Prevent or correct problems early. Encourage employees to report problems internally, rather than to outside agencies. Minimize financial loss to the government and taxpayers. IMAGE: 2006.GIF Page 6 of 9

12 2007 Benefits of a Compliance Program Finally, an effective compliance program may reduce penalties, if misconduct happens. IMAGE: 2007.JPG If misconduct happens, the facility might: Not be prosecuted. Have lower fines. Not be placed under government watch or probation. Page 7 of 9

13 2008 Review A good compliance program helps your facility increase its: a. Cost of healthcare b. Quality of patient care c. Ability to correct misconduct early d. Both B and C e. All of the above MULTIPLE CHOICE INTERACTION Correct: D Response to A: Incorrect. The correct answer is D. Response to B: Not quite. The best answer is D. Response to C: Not quite. The best answer is D. Response to D: Correct. Response to E: Incorrect. The correct answer is D. Page 8 of 9

14 2009 Summary You have completed the lesson on the importance of compliance and compliance programs. NO IMAGE Remember: Government agencies are looking closely at healthcare. The penalties for misconduct can be big. A good compliance programs helps prevent misconduct. A good compliance program has other benefits, too. Page 9 of 9

15 Lesson 3: Laws and Regulations 3001 Introduction & Objectives Welcome to the lesson on laws and regulations. After completing this lesson, you should be able to: List keys laws and regulations for healthcare. Identify the important points of each law. Recognize the penalties for breaking each law. FLASH ANIMATION: 3001.SWF/FLA Page 1 of 16

16 3002 Laws and Regulations Important laws and regulations for healthcare are: Medicare regulations Federal False Claims Act Stark Act Anti-Kickback (link to glossary) Statute Sections of the Social Security Act Mail and wire fraud statutes Patient Anti-Dumping Statute HIPAA Privacy Rule IMAGE: 3002.JPG On the following screens, let s take a closer look at each. Page 2 of 16

17 3003 Medicare Regulations Any facility that participates in Medicare must follow Medicare regulations. IMAGE: 3003.GIF For example, facilities must: Meet standards for quality of care Not bill Medicare for unnecessary items or services Not bill Medicare for costs or charges that are significantly higher than the usual cost or charge Follow other rules for claims and billing A facility may be excluded from Medicare if it does not follow Medicare regulations. Page 3 of 16

18 3004 False Claims Act The Federal False Claims Act makes it illegal to submit a falsified bill to a government agency. The Federal False Claims Act: Applies to healthcare Contains a whistleblower provision Carries a penalty for violation Click on each to learn more. Several states have laws focusing on False Claims in addition to the Federal False Claims Act. If your institution receives >$5 million in Medicaid payments, you will receive written policies detailing these laws, the Federal False Claims Act provisions, and remedies for False Claims. [CLICK TO REVEAL] Healthcare Application The Federal False Claims Act applies to healthcare because Medicare is a government agency. Improper Medicare billing is a serious problem and often involves billing for lab tests. For example, hospitals cannot bill for outpatient services (such as preadmission tests) that are covered by Medicare Inpatient Payment. In addition, it is fraudulent to charge for tests that were not performed or to unbundled lab tests that were performed as a group at the same time. Whistleblower Provision A whistleblower is a citizen who has evidence of fraud covered by the False Claims Act. The whistleblower provision allows this person to sue on behalf of the government and protects the whistleblower from retaliation for reporting the fraud. If the lawsuit is won, the whistleblower receives a share of the funds recovered. Violation Penalties A provider who violates the Federal False Claims Act may be fined: Up to $11,000 per false claim Up to triple damages for the billed amount Page 4 of 16

19 3005 Stark Act The Ethics in Patient Referrals Act (EPRA) is commonly known as the Stark Act. IMAGE: 3005.GIF This Act makes it illegal for physicians to refer patients to facilities or providers: If the physician has a financial relationship with the facility or provider If the physician s immediate family has a financial relationship with the facility or provider Note: This law does not apply in certain cases. Page 5 of 16

20 3006 Stark Act: Penalties Possible penalties for violating the Stark Act are: Not being paid for services Having to refund payment for services Civil penalties of up to $15,000 per illegal referral Civil penalties of up to $10,000 per day for organizations that do not report details of violations Fines of up to $100,000 for each illegal referral Exclusion from Medicare IMAGE: 3006.GIF Page 6 of 16

21 3007 Anti-Kickback Statute The Medicare and Medicaid Patient Protection Act of 1987 is commonly known as the Anti-Kickback Statute (or AKBS). IMAGE: 3007.GIF This law makes it illegal to ask for or receive kickbacks, bribes, or rebates for: Referring a patient for an item or service that will be paid for by a government program (such as Medicare) Purchasing an item or service that will be paid for by a government program The AKBS also makes it illegal to offer or pay a kickback, bribe, or rebate related to a Medicare item or service. Note: This law does not apply in certain cases. Page 7 of 16

22 3008 Anti-Kickback Statute: Penalties Possible penalties for violating the AKBS are: $25,000 fine Up to five years in jail Exclusion from Medicare and Medicaid IMAGE: 3008.GIF Page 8 of 16

23 3009 Sections of the Social Security Act The Social Security Act makes it illegal for hospitals to: Knowingly pay physicians, to encourage them to limit services to Medicare or Medicaid patients. Offer gifts to Medicare or Medicaid patients, to get their business IMAGE: 3009.GIF Either violation may be penalized with a fine. Page 9 of 16

24 3010 Mail and Wire Fraud Statutes Mail and wire fraud statutes make it illegal to use the U.S. Mail or electronic communication as part of a plan to defraud (link to glossary). IMAGE: 3010.GIF For example, these statutes make it illegal to mail a fraudulent bill to Medicare. Penalties are: Fines of up to $250,000 Up to 30 years in jail Page 10 of 16

25 3011 EMTALA The Emergency Medical Treatment and Active Labor Act (EMTALA) is commonly known as the Patient Anti-Dumping Statute. IMAGE: 3011.GIF This statute requires Medicare hospitals to provide emergency services to all patients. These services are: Medical screening for patient who may have an emergency condition Stabilizing care for patients who do have an emergency condition Hospitals must provide these services, whether or not the patient can pay. Page 11 of 16

26 3012 Patient Anti-Dumping Statute: Penalties If a hospital violates EMTALA, possible penalties are: Up to $50,000 per violation for hospitals with 100 beds or more Up to $25,000 per violation for hospitals with fewer than 100 beds Exclusion from Medicare IMAGE: 3012.GIF Page 12 of 16

27 3013 HIPAA Privacy Rule The HIPAA Privacy Rule protects the patient s right to privacy of health information. IMAGE: 3013.GIF Page 13 of 16

28 3014 HIPAA Privacy Rule: Penalties Civil penalties for violation of HIPAA are: Up to $100 per violation Up to $25,000 per calendar year for multiple violations IMAGE: 3014.GIF Criminal penalties are: Fine of up to $50,000 and jail time up to one year for knowingly obtaining or revealing protected health information (PHI) Fine of up to $100,000 and jail time up to five years for obtaining or revealing PHI under false pretenses Fine of up to $250,000 and jail time up to ten years for obtaining or revealing PHI and intending to use the information for gain or harm Page 14 of 16

29 3015 Review FLASH INTERACTION: 3015.SWF/FLA Drag the correct statute or regulation from the answer bank into the appropriate blank. False Claims Act makes it illegal to bill the government falsely Stark Act makes it illegal for physicians to refer patients to providers or facilities, if they have a financial relationship with the provider or facility Anti-Kickback Statute makes it illegal to give or take kickbacks, bribes, or rebates related to goods or services that will be covered by Medicare Mail and wire fraud statute makes it illegal to use the U.S. Mail or electronic communication as part of a scheme to defraud Patient Anti-Dumping Statute requires Medicare hospitals with emergency rooms to provide emergency services to all patients HIPAA Privacy Rule protects the patient s right to privacy Page 15 of 16

30 3016 Summary You have completed the lesson on laws and regulations. Remember: Medicare regulations are rules for participating in Medicare. The False Claims Act makes it illegal to bill a government agency falsely. The Stark Act makes it illegal for physicians to make certain types of referrals. The Anti-Kickback Statute makes it illegal to give or take kickbacks, bribes, or rebates related to Medicare. Mail and wire fraud statutes make it illegal to use the U.S. Mail or electronic communication as part of a plan to defraud. Under EMTALA, all Medicare hospitals with emergency rooms must provide emergency services to all patients. The HIPAA Privacy Rule protects the patient s right to privacy of health information. Each of these rules has severe penalties for violators. NO IMAGE Page 16 of 16

31 Lesson 4: Components of a Compliance Program 4001 Introduction & Objectives Welcome to the lesson on parts of an effective compliance program. FLASH ANIMATION: 4001.SWF/FLA After completing this lesson, you will be able to: List the parts of an effective compliance program. Identify the role of each part. List high-risk areas for healthcare misconduct. Recognize how your facility s compliance program helps you do your job in a legal and ethical way. Page 1 of 22

32 4002 Function of Compliance Programs As we have seen, your facility must follow many laws and rules. IMAGE: 4002.JPG A good compliance program helps your facility do this Page 2 of 22

33 4003 Code of Conduct An effective compliance program begins with a clear commitment to compliance. IMAGE: 4003.GIF Each hospital should value and encourage compliance. The Office of the Inspector General (OIG) recommends that each facility should have a code of conduct. This code should state the facility s commitment to legal and ethical conduct. Page 3 of 22

34 4004 How a Compliance Program Works In addition to a code of conduct, the OIG also recommends seven specific parts of a compliance program. NO IMAGE These seven parts are: A compliance officer and compliance committee Compliance policies and procedures Open lines of communication Training and education Internal auditing and monitoring (link to glossary) Response to problems Enforcement of discipline On the following screens, let s take a closer look at each part. Page 4 of 22

35 4005 Program Elements: Compliance Officer & Committee Each facility should have a compliance department. IMAGE: 4005.GIF This department is at the heart of the compliance program. The compliance department should have: A compliance officer from senior management A compliance committee The compliance department: Puts the compliance program into effect Makes sure that the facility follows all the rules of federal healthcare programs Page 5 of 22

36 4006 Program Elements: Policies & Procedures Written policies and procedures give rules that help employees do their jobs legally and ethically. IMAGE: 4006.JPG Written policies and procedures are different than the code of conduct: The code is a brief description of overall values, principles, and commitment to compliance. Written policies and procedures are far more detailed and specific. In particular, written policies and procedures should address high-risk areas for healthcare compliance. Let s review high-risk areas on the following screens. Page 6 of 22

37 4007 High-Risk Areas Remember: Claims and billing are the biggest risk areas for compliance in healthcare. IMAGE: 4007.GIF These high-risk areas include two general types of risks: Long-standing issues Evolving issues Let s take a closer look at each. Page 7 of 22

38 4008 High-Risk Areas: Longstanding Risks Examples of longstanding risks associated with claims include: Duplicate billing Unbundling Upcoding Performing and billing for medically unnecessary services Billing for services or supplies not provided Click on each item in the bulleted list for more information. CLICK TO REVEAL Duplicate billing This refers to illegally: Billing twice for the same service or procedure Billing more than one payer for the same service This is fraudulent. Unbundling This refers to billing separately for tests or procedures that should be billed together at a lower overall cost. Separate bills increase payment to the provider. This is fraudulent. Upcoding This refers to using a billing code that increases payment to the provider, instead of using the correct billing code for the service provided. This is fraudulent. Medically unnecessary services Medicare does not allow billing for medically unnecessary services. Services or supplies not provided It is illegal to bill Medicare for services or supplies not provided. This would be a violation of the False Claims Act. Page 8 of 22

39 4009 High-Risk Areas: Evolving Risks In its 2005 supplemental compliance guidance for hospitals, the OIG identified four categories of evolving high-risk areas. These categories are: Outpatient procedure coding Admissions and discharges Supplemental payment Use of information technology Click on each category for more information. CLICK TO REVEAL Outpatient procedure coding Risk areas in this category are: Billing staff who are not properly trained or qualified to do coding Medical records that are incomplete or do not support claims Billing on an outpatient basis for inpatient-only procedures Submitting claims for medically unnecessary services, because of not following the local policies of the Fiscal Intermediary (FI) [glossary] Not following the National Correct Coding Initiatives (NCCI) [glossary] guidelines Submitting incorrect claims because of outdated charge masters [glossary] Not following the rules for discounting multiple procedures Selecting improper codes for evaluation and management (E/M) services Billing improperly for observation services Admissions and discharges Risk areas in this category are: Not following the same-day rule, which requires hospitals to submit a single claim for all services provided to the same patient, at the same hospital, on the same day (with certain exceptions) Abusing the partial hospitalization program, which provides payment for certain services to partially hospitalized mental health patients Discharging and readmitting a patient on the same day Not following Medicare s policy for transferring patients after they have received acute care Improper transfer of patients between an acute care hospital and a long-term care facility within the hospital Supplemental payments Risk areas in this category are: Improper reporting of costs of pass-through items, which are items that Medicare will pay for only during a limited time period Abuse of DRG outlier payments Improperly identifying certain items as provider-based, to increase payment Improper claims for clinical trials Improper claims for costs of acquiring certain donated organs Improper claims for cardiac rehab services Not following Medicare rules for payment of costs of educational activities Use of information technology More and more, hospitals are using computer systems and software for coding and billing. Your facility should be sure to check all new computer systems and software, to make sure that coding and billing remains accurate. Page 9 of 22

40 4010 Program Elements: Effective Lines of Communication Lines of communication must be open and effective to support the compliance program. IMAGE: 4010.JPG Open communication increases the ability to: Identify problems early. Correct problems promptly. On the following screens, let s take a closer look at: Management responsibilities for open communication Staff responsibilities for open communication The compliance hotline Page 10 of 22

41 4011 Effective Lines of Communication: Management Responsibilities Management is responsible for: Training and educating staff on how to spot and report misconduct Responding properly to employee reports of misconduct Not revealing the identity of staff members who wish to report misconduct anonymously [glossary] Protecting staff members from retaliation for reporting misconduct IMAGE: 4011.JPG Page 11 of 22

42 4012 Effective Lines of Communication: Staff Responsibilities Staff members are responsible for: Knowing how to spot and report misconduct Reporting misconduct NOT retaliating against employees who report misconduct IMAGE: 4012.JPG Page 12 of 22

43 4013 Effective Lines of Communication: Compliance Hotline Employees should have several ways to report misconduct. One of these should be a compliance hotline. IMAGE: 4013.JPG An employee may use the hotline to: Report misconduct anonymously Re-report misconduct, if a first report is ignored Page 13 of 22

44 4014 Effective Lines of Communication: Compliance Hotline Hotline calls should: Allow the caller to remain anonymous. Be handled in strict confidence. Be handled in a way that protects the privacy of any patient involved. Lead to an investigation. IMAGE: 4014.GIF Page 14 of 22

45 4015 Program Elements: Training and Education Proper education and training are another important part of a good compliance program. Training ensures that everyone at your facility knows how to do his or her job in a legal way. IMAGE: 4015.JPG Training should: Give general information about your facility s compliance program. Stress your facility s commitment to compliance. Give specific information about the rules and laws you need to know to do your job properly The Deficit Reduction Act of 2005, as of January 1, 2007, requires all entities making or receiving >$5 million in Medicaid payments to provide its employees, contractors, and agents with written policies detailing: The provisions of the Federal False Claims Act (covered in lesson 2) Remedies for the Federal False Claims Act State laws for False Claims Whistleblower protection under False Claims Acts (covered in lesson 2) Page 15 of 22

46 4016 Program Elements: Monitoring and Auditing Compliance requires ongoing monitoring and auditing. IMAGE: 4016.JPG Your facility should do a detailed annual audit to be sure that Medicare and Medicaid are not billed incorrectly. Page 16 of 22

47 4017 Program Elements: Response to Compliance Problems An effective compliance program should allow for a prompt response to any compliance problems. IMAGE: 4017.GIF All reported or suspected problems should be investigated. If the investigation shows that there is a problem, the problem should be corrected right away. The plan for correction may include: Notifying law enforcement Self-reporting to government agencies Reimbursement of any overpayments Looking into the root causes of the problem Discipline for the employees involved Page 17 of 22

48 4018 Program Elements: Enforcement of Discipline Disciplinary standards for noncompliant employees should be well-publicized. IMAGE: 4018.GIF For a compliance program to be effective, these standards must be used consistently. All types of employees should be disciplined in the same way for similar misconduct. Page 18 of 22

49 4019 Tools for Compliance In short: An effective compliance program gives you and your facility tools for working ethically and legally. Remember: The tools of particular use to you are: Compliance officer and compliance committee Written policies and procedures Effective lines of communication Training and education Click on each for a brief review. CLICK TO REVEAL Compliance officer and compliance committee You may report misconduct directly to the compliance officer at any time. Consult the compliance officer or committee about any compliance questions. Written policies and procedures Review your organization s compliance plan. Effective lines of communication Report misconduct according to your organization s policies and procedures. Training and education Attend all required training sessions. This will keep you informed about how to stay compliant. Page 19 of 22

50 4020 Review A code of conduct is the same thing as written policies and procedures for corporate compliance. a. True b. False TRUE / FALSE INTERACTION Correct: B Feedback for A: Incorrect. This statement is false. A code of conduct is a brief statement of principles and values. Written policies and procedures are detailed and specific. Feedback for B: Correct. This statement is false. A code of conduct is a brief statement of principles and values. Written policies and procedures are detailed and specific. Page 20 of 22

51 4021 Review You are preparing a Medicare claim. The patient received a series of services that should be submitted on a single claim. It is okay to unbundle these services if: a. You do not upcode any of the services. b. All of the services were medically necessary. c. Unbundling will increase payment to your hospital. d. All of the above e. None of the above MULTIPLE CHOICE INTERACTION Correct: E A: Incorrect. The correct answer is E. Unbundling is fraudulent. It is never okay. B: Incorrect. The correct answer is E. Unbundling is fraudulent. It is never okay. C: Incorrect. The correct answer is E. Unbundling is fraudulent. It is never okay. D: Incorrect. The correct answer is E. Unbundling is fraudulent. It is never okay. E: Correct. Unbundling is fraudulent. It is never okay. Page 21 of 22

52 4022 Summary You have completed the lesson on the parts of a compliance program. NO IMAGE Remember: Your facility should have a code of conduct. Review this code. The OIG recommends seven parts for a compliance program. Be aware of these. Know how to use each to help you do your job legally and ethically. Page 22 of 22

53 Course Glossary # Term Definition 1. allegation something stated to be true 2. anonymous having an unknown or withheld name 3. charge master a provider s list of prices for services and supplies, which also lists the billing code for each service or supply 4. compliance to agree to or go along with a wish, request, or demand 5. confidential told in secret 6. defraud to cheat 7. deter to prevent or discourage 8. ethics study and practice of human conduct which upholds moral values, rules, and principles 9. ethical what is right or wrong, good or bad, based on reasoned principles 10. forge to copy for unfair or unlawful gain 11. fraud cheating for unfair or unlawful gain; falsifying information to collect undeserved money 12. fraudulent a description of an action that involves cheating for unfair or unlawful gain 13. kickback a payment to a person able to control a source of income 14. Medicare the federal health insurance program that provides medical benefits to persons 65 years old or over and to other designated individuals 15. monitor to listen, watch carefully 16. noncompliance not agreeing to or going along with a wish, request, or demand 17. oversight providing supervision 18. prosecute take legal action against 19. refer to direct to help or information 20. regulations governmental orders having the force of law 21. scheme a plan or plot 22. upcoding using a billing code that provides a higher payment rate than the billing code that accurately reflects the service rendered to the patient

54 23. unbundling submitting separate bills to maximize reimbursement for tests or procedures that are required to be billed together at reduced total cost 24. National Correct Coding A set of policies developed by CMS to promote national correct coding methodologies and Initiative control improper coding that leads to inappropriate payment of certain health insurance claims 25. Fiscal Intermediary An organization that acts as a go-between for an agency that gives out money and the recipients of that money

55 PA TEST 1. Claims and billing are the biggest risk areas for healthcare fraud and abuse. a. True b. False Correct Answer: A Rationale: This statement is true. 2. A healthcare facility has a good compliance program. This program can help: a. (a) Increase the risk of whistleblower suits b. (b) Reduce the risk of penalties if there is misconduct c. (c) Create a culture committed to legal and ethical practices d. Both B and C e. All of the above Correct Response: D Rationale: An effective compliance program helps create a culture of ethics. It reduces the risk of penalties in case misconduct happens. It is also likely to reduce the risk of whistleblower suits. This is because the program provides a way to deal with problems internally. 3. A Medicare patient comes to your facility with a sore throat and fever. You perform a rapid strep test. This confirms that the patient has strep throat. Antibiotics are prescribed. The patient is sent home. Later, charges for a urinalysis and complete blood count are added to the Medicare bill. This is a violation of the: a. Stark Act b. False Claims Act c. Anti-Kickback Statute d. Patient Anti-Dumping Act Correct Answer: B Rationale: The False Claims Act makes it illegal to submit a false bill to a government agency. 4. You see Medicare patients at a walk-in clinic. Your facility decides to make a deal with Dr. Goodheart, a local cardiologist. Whenever a Medicare patient needs a heart specialist, your facility refers the patient to Dr. Goodheart. In exchange, Dr. Goodheart pays your facility 10% of his Medicare reimbursements. In this case, who is violating the Anti-Kickback Statute? a. Only your facility b. Only Dr. Goodheart c. Both your facility and Dr. Goodheart d. Neither your facility nor Dr. Goodheart Correct Answer: C

56 Rationale: The Anti-Kickback Statute (AKBS) makes it illegal to GIVE or TAKE bribes, rebates, or kickbacks related to Medicare services. 5. A 55-year-old male patient with a family history of early heart disease comes to your facility. A lipid panel (HDL cholesterol, LDL cholesterol, and triglycerides) is performed. The patient s insurance company is billed. However, your facility does not submit a single bill. Instead, separate bills for each test are submitted, to increase payment. This is an example of: a. Upcoding b. Unbundling c. Duplicate billing d. Standard billing practice Correct Answer: B Rationale: Unbundling means submitting separate bills to increase payment for tests or procedures that should be billed together at a lower total cost. This is a fraudulent billing practice. 6. Written compliance programs and policies should be general. They should not address any particular areas in which problems might come up. a. True b. False Correct Answer: B Rationale: Written compliance programs and policies should address specific high-risk areas. 7. Proper education and training are critical elements of an effective compliance program. a. True b. False Correct answer: A Rationale: This statement is true. 8. Use the compliance hotline to: a. (a) Report a compliance problem anonymously. b. (b) Retaliate against a coworker who accuses you of non-compliance. c. (c) Report a compliance problem that your supervisor is not taking seriously. d. Both A and C e. All of the above Correct Answer: D Rationale: The compliance hotline allows anonymous reports. The hotline also can be used to report problems that a supervisor has ignored. It is unacceptable to retaliate against an employee who reports a compliance problem. 9. An employee and his or her supervisor perform similar acts of noncompliance. In this case:

57 a. Only the employee should be punished. b. Only the supervisor should be punished. c. The supervisor should be punished more severely than the employee. d. The employee and supervisor should be punished in the same manner. Correct Answer: D Rationale: All levels of employees should be disciplined in the same way for similar acts of noncompliance. 10. should be investigated. a. All reports of compliance problems b. Only compliance problems with a paper trail c. Only compliance problems reported via the compliance hotline d. Only compliance problems reported by trusted, long-time employees Correct Answer: A Rationale: All reports should be investigated.

58 Final Exam Question Title: Question 1 Question: Incorrect coding on a bill to Medicare: Answer 1: Is never caught Answer 2: Is healthcare fraud Answer 3: Is a harmless mistake Answer 4: Is necessary to increase payment Correct Answer: Is healthcare fraud Answer Rationale: Incorrect coding is healthcare fraud. This is true even if it happens because of ignorance or an error. Question Title: Question 2 Question: Choose the true statement. If an employee reports a compliance problem: Answer 1: The problem should be investigated. Answer 2: The compliance officer should decide whether to investigate. Answer 3: The compliance committee should decide whether to investigate. Answer 4: The supervisor who receives the report should decide whether it is worth investigating Correct Answer: The problem should be investigated. Answer Rationale: All reports of compliance problems should be investigated. Question Title: Question 3 Question: Choose the part(s) of an effective compliance program: Answer 1: (a) A compliance officer

59 Answer 2: (b) Written policies for specific high-risk areas Answer 3: (c) Day-to-day oversight by the Office of the Inspector General Answer 4: Both A and B Answer 5: All of the above Correct Answer: Both A and B Answer Rationale: The OIG offers guidance for compliance. It does not supply day-to-day oversight. Question Title: Question 4 Question: Compliance programs allow organizations to deal with misconduct internally. Answer 1: True Answer 2: False Correct Answer: True Answer Rationale: This statement is true. Question Title: Question 5 Question: Choose the true statement(s). Answer 1: (a) Employees may report compliance problems anonymously. Answer 2: (b) The compliance hotline is one of several ways to report compliance problems. Answer 3: (c) Reports of compliance problems should be handled in a way that protects the privacy of any patients involved. Answer 4: Both A and B Answer 5: All of the above Correct Answer: All of the above Answer Rationale: All of these statements are true of reporting misconduct. Question Title: Question 6 Question: means submitting separate bills, instead of a single claim for tests or procedures that should be billed together at a lower total cost.

60 Answer 2: Kickback Answer 1: Upcoding Answer 4: Unbundling Answer 3: Duplicate billing Correct Answer: Unbundling Answer Rationale: This describes unbundling. Unbundling is fraudulent. Question Title: Question 7 Question: The makes it illegal for physicians to refer patients to a facility or provider, if they have a financial relationship with that facility or provider. Answer 1: Stark Act Answer 2: False Claims Act Answer 4: HIPAA Privacy Rule Answer 3: Anti-Kickback Statute Correct Answer: Stark Act Answer Rationale: The Stark Act enforces ethics in referrals. Question Title: Question 8 Question: The makes it illegal to give or take rebates related to goods or services that Medicare will pay for. Answer 1: Stark Act Answer 2: False Claims Act Answer 3: Anti-Kickback Statute Answer 4: Patient Anti-Dumping Statute Correct Answer: Anti-Kickback Statute Answer Rationale: The Anti-Kickback Statute makes it illegal to give or take rebates, bribes, or kickbacks related to Medicare.

61 Question Title: Question 9 Question: Retaliating against an employee for reporting a compliance problem: Answer 1: (a) Is an accepted practice Answer 2: (b) Is a good way to keep communication open Answer 3: (c) Is a practice that should be prohibited and prevented by management Answer 4: Both A and B Answer 5: All of the above Correct Answer: Is a practice that should be prohibited and prevented by management Answer Rationale: Management is responsible for protecting employees from retaliation for reporting compliance problems. This helps keep communication open. Question Title: Question 10 Question: It is legal for hospitals to: Answer 1: (a) Offer gifts to Medicare patients to get their business. Answer 2: (b) Offer kickbacks to local physicians for referring Medicare patients. Answer 3: (c) Make payments to physicians to encourage them to limit services to Medicare patients. Answer 4: Both A and C Answer 5: None of the above Correct Answer: None of the above Answer Rationale: These are all illegal.