AHFI Exam | 168 Questions and Answers
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - ANSWER
-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...
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - ANSWER
-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 - ANSWER -
Voluntary safe harbors
Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - ANSWER -
All Federal Health Care Programs
The Stark Law (42 US SS 139nn) Prohibition - ANSWER -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 - ANSWER -Referrals from a
physician
The Stark Law (42 US SS 139nn) (Items/Services) - ANSWER -Designated health
services
The Stark Law (42 US SS 139nn) (Intent) - ANSWER -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 - ANSWER -
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) - ANSWER -Mandatory
exceptions
The Stark Law (42 US SS 139nn) applies to - ANSWER -Medicare and Medicaid
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 - ANSWER -To correct the behavior in
need of change and prevent future inappropriate billing
The priority of MACs - ANSWER -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 - ANSWER -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 - ANSWER -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 - ANSWER -The MACs
shall initiate a targeted provider-specific prepayment review only when there is the
likelihood of sustained or high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review to prevent
improper payments for services identified by C ERT or Recovery Auditors as
problem areas, as well as, problem areas identified by their own data analysis
Cert Contractors and reviews - ANSWER -Because the Cert Contractors select
claims on a random basis, they are not required to notify providers of their
intention to begin a review.
Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - ANSWER -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 - ANSWER -Referrals
from anyone
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