AHFI Exam Questions and answers, 100% Accurate, rated A+. QuizBank
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AHFI Exam Questions and answers, 100% Accurate, rated A+. QuizBank
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - -Prohibits offering, paying, soliciting or reviving anything of value to induce or reward referrals or generate Federal health care program business
Anti-Kickback S...
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AHFI Exam Questions and answers,
100% Accurate, rated A+. QuizBank
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - ✔✔-Prohibits offering, paying, soliciting or
reviving anything of value to induce or reward referrals or generate Federal health care program
business
Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - ✔✔-Referrals from anyone
Anti-Kickback Statute (42 US SS 1320a-7b (b) - ✔✔-Any items or services
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Intent) - ✔✔-Intent MUST be proven (knowing and willful)
Anti-Kickback Statute (42 US SS 1320a-7b (b) Criminal penalties - ✔✔-Fines up to $25,000/violation
Up to a 5-yr prison term/violation
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - ✔✔-False Claims act liability
Civil monetary penalties and program exclusions
Potential $50,000 CMP/violation
Civil assessment of up to 3x amount of kickback
Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - ✔✔-Voluntary safe harbors
,Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - ✔✔-All Federal Health Care
Programs
The Stark Law (42 US SS 139nn) Prohibition - ✔✔-Prohibits a physician from referring Medicare patients
for designated health services to an entity with which the physician (or immediate family member) has a
financial relationship, unless an exception applies)
Prohibits the designated health services entity from submitting claims to Medicare for those services
resulting from a prohibited referral
The Stark Law (42 US SS 139nn) Referrals - ✔✔-Referrals from a physician
The Stark Law (42 US SS 139nn) (Items/Services) - ✔✔-Designated health services
The Stark Law (42 US SS 139nn) (Intent) - ✔✔-No intent standard for overpayment (strict liability)
Intent required for civil monetary penalties for knowing violations
The Stark Law (42 US SS 139nn) (Civil Penalties) only - ✔✔-Overpayment/refund obligation
False Claims Act liability
Civil monetary penalties and program exclusion for knowing violations
Potential $15,000 CMP for each service
Civil assessment of up to 3x the amount claimed.
The Stark Law (42 US SS 139nn) (Exceptions) - ✔✔-Mandatory exceptions
, The Stark Law (42 US SS 139nn) applies to - ✔✔-Medicare and Medicaid
(No commercial or tricare)
MACs: - ✔✔-Medicare Administrative Contractors
They analyze claims to determine provider compliance with Medicare coverage, coding, and billing rules
and take appropriate corrective action when providers are found to be non-compliant.
The goal of Mac administrative actions - ✔✔-To correct the behavior in need of change and prevent
future inappropriate billing
The priority of MACs - ✔✔-To minimize potential future losses to the Medicare Trust Fund through
targeted claims review while using resource efficiently and treating providers and beneficiaries fairly.
For repeated infractions, MACs have - ✔✔-The discretion to initiate progressively more severe
administrative action, commensurate with the seriousness of the identified problem. (See Program
Integrity Manual (PIM) chapter 3, SS3. 7.1)
Medicare Fee For Service Recovery Audit Program - ✔✔-Legislative mandated program (Tax Relief and
Health Care act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by Medicare to fee-for-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return underpayment.s.
MACs targeted provider-specific prepayment review - ✔✔-The MACs shall initiate a targeted provider-
specific prepayment review only when there is the likelihood of sustained or high level of payment
error.
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