WHAT IS THE IMPORTANCE OF AUDIT IN A PRACTICE? - answer✔1. Reviewing quality
of care provided to patients. 2. Educating providers on documentation. 3. Ensuring all services
are supported and all appropriate revenue is captured. 4. Defending against external audit
malpractice litigation and health plan request and denial.
Exclusion Statute - answer✔1.Physician is banned from participating in any federal or state
healthcare program by OIG 2. They can't bill federal or state for any services provided .3 length:
host less than five years .4 When exclusionary period has ended dr must apply for reinstatement
and receive authorize notice from OIG that reinstate has been granted
Abuse - answer✔In action resulting in unnecessary cost to a federal healthcare program either
directly or indirectly
What is the civil penalty - answer✔Not less than 5000 and not more than 10,000 per claim x3
times the amount of government damages
Federal False Claims Act - answer✔Having knowledge that claims is fake.
.1 knowing and knowingly that a person must act in deliberate ignorance of the truth or falsely of
the relevant information or act in a reckless manner of the truth or falsity of the Information
Qui Tam - answer✔whistleblower
what percentage is offered for a whistleblower/qui tam as an award from what is recovered by
the government? - answer✔between 15% and 25%
fraud - answer✔Knowingly making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from federal healthcare program
Discovery sample - answer✔CIA - 50 samples units randomly selected *determines the net
financial error rate .2 if error rate exceeds 5% a full sample must be reviewed
HHS OIG 3 core publications - answer✔1.work plan
2.semiannual report to congress
non-compliant conduct must be documented in compliance files & should include - answer✔1.
date of incident
2.name of the reporting party
3.name of the person responsible for taking action
4.the follow up the action taken
What is an auditor - answer✔Reviews healthcare providers policies add procedures to ensure
compliance with applicable requirements
cms uses what avenues to deliver Information - answer✔1.webcasts
2. transmitting
3.manuals
4.the medicare learning network
CIA
Corporate Integrity Agreement - answer✔Last five years can be longer if OIG likes OIG will
require CIA as a condition for not seeking exclusion from participation when they seek to settle
civil fraud cases requirements hearing compliance officer/ appointments compliance committee ,
employee training program,IRO
(IRO) independent review organization - answer✔(Third-party medical review resource) 1.
Provides objective unbiased audits and reports. 2. OIG can notify provider within 30 days if IRO
is unacceptable and may request IRO be terminated and another IRO be retained.
Civil Monetary Penalties Law (CMP) - answer✔(Improper filing of claims- Upcoding,
miscoding) 1. Knowing it's a false claim. 2. Knowing Dr. is not licensed. 3. Changing DOS to
when PT was effective with a government plan. 4. Knowing it's not medically necessary.
*Penalties 10,000 to 50,000 per violation up to $22,363 for each item/service and 3X the amount
improperly claimed. If disagree* can request hearing before an HHS administrative law judge.
Anti-Kickback Law - answer✔(Applies to anyone not just physicians) receiving cash or payment
knowingly that it is illegal for referring people to doctor's office. *intent must be proven* $25,00
per violation - up to 5 years in prison
(OIG) Office of Inspector General responsibilities - answer✔To detect and prevent fraud, waste,
abuse and violations of law, and to promote economy, efficiency and effectiveness in the
operations of the federal government.
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