Anti-kickback statute - ANSWER The Social Security amendments of 1972 included the
original anti-kickback legislation the legislation stated the statute was to prevent fraud and
abuse from federal healthcare programs. A criminal statute that provides exchange of any-
thing of value in an effort to induce or reward the referral of federal healthcare program
business. If fined up to $25,000 and imprisonment up to five years
Safe harbors under anti-kickback statute? - ANSWER Safe harbors immunize certain pay-
ments and business practices that are implicated by the anti-kickback statute from criminal
and civil prosecution under the statute to be protected in a safe harbor and arrangement
must fit squarely in the safe harbor
Examples of safe harbors - ANSWER Safe harbors include investments in ambulatory sur-
gical centers, joint ventures in underserved areas, practitioner recruitment in underserved
areas, sales a physician practices to hospitals in underserved areas, subsidiaries for obstetri-
cal malpractice insurance in underserved areas, investment in group practices, specialty re-
ferral arrangements between providers, cooperative the hospital service organizations
Seven elements of program for individual and small group physician practices - ANSWER
The seven elements are conducting internal monitoring and auditing, implementing compli-
ance and practice standards, designating a compliance officer or contact, conducting appro-
priate training and education, responding appropriately to detected offenses and developing
corrective action, developing open lines of communication, and enforcing disciplinary stand-
ards through well-publicized guidelines
Benefits of a voluntary compliance program - ANSWER Speed and optimize proper pay-
ment of claims, minimize mistakes, reduce the chances that an audit will be conducted by
HCFA or that OIG and, avoid conflicts with the self referral and anti-kickback statute
1
,Difference between erroneous and fraudulent claims to federal healthcare programs - AN-
SWER Fraudulent claims intentionally or recklessly are submitted to federal healthcare
programs. Erroneous claims are innocent errors submitted unintentionally to federal
healthcare programs
What responsibility do healthcare providers have to federal healthcare programs? - AN-
SWER Federal healthcare providers have a duty to reasonably ensure that the claim sub-
mitted to Medicare and other federal healthcare programs are true and accurate
What are the steps for auditing and monitoring evaluations - ANSWER Ensure that the
standards and procedures are in fact current and accurate but also whether the compliance
program is working. following steps a standards and procedures review and claim submis-
sion audit
What do you validate reviewing policies and procedures? - ANSWER Validate they are
current and accurate if standards and procedures are found to be ineffective or outdated
they should be updated to reflect changes in government regulations or compendiums gen-
erally relied upon by physicians and insurance for example CPT and ICD-10 codes
Who should be involved in a claim submission audit? - ANSWER The person in charge of
billing and a medically trained person to audit the records
What should physicians practice do if they are using another entities compliance materials? -
ANSWER They need to tailor the materials to be applied by the physician practice starting
by the following, 1) develop written standards and procedures 2) updating clinical forms 3)
make sure they facilitate encouraging clear and complete documentation of patient care
What are the four basic risk areas developed by the OIG? - ANSWER 1) coding and billing
2) reasonable and necessary services 3) documentation 4) improper inducements
What are the biggest risks with coding and billing? - ANSWER Billing for services not ren-
dered or provided by as claimed, submitting claims for equipment medical supplies and ser-
vices that are not reasonable and necessary, double billing resulting in duplicate payments,
2
,billing for noncovered services as if covered, knowing misuse of a provider identification
numbers which results in improper billing, unbundling billing for each component of service
instead of billing for all inclusive code, failure to properly use Coding modifiers, and a coding
the level of service provided
What are the risks with the physician documentation? - ANSWER The risks are documen-
tation is not performed timely and accurate. it is incomplete, it does not reflect appropriate
documentation of the diagnosis and treatment plan
What are examples of internal documentation guidelines a practice could use? - ANSWER
Examples of internal documentation guidelines are the medical record is complete and legi-
ble, the documentation for each patient encounter includes the reason for the encounter
any relative history, physical examination, findings prior to diagnostic test results, assess-
ment clinical impression or diagnosis plan of care and date of legible Identity of the other
observer
What is one method for improving quality in documentation? - ANSWER The method is
to compare the practices claim denial rate to the rates of other practices in the same spe-
cialty to the extent of the practice can obtain that information from the carrier. Physician
coding and diagnoses distribution can be compared for each physician with the same spe-
cialty to identify variances.
What are areas to monitor for that HCFA 1500 form? - ANSWER Linking the diagnosis
code to the visit service, use of modifiers appropriately, provide Medicare with all infor-
mation about beneficiaries other insurance coverage under Medicare secondary payer pol-
icy, improper inducements kickbacks and self referrals
Improper Inducements , Kickbacks and Self-Referrals. - ANSWER Remuneration for refer-
rals is illegal because it can distort medical decision-making, cause overutilization of services
or supplies, increase costs to Federal health care
Areas to consider for improper inducements? - ANSWER Financial arrangements with
outside entities to home practice may refer federal healthcare program business, joint ven-
tures with entity supplies goods or services to physician practice or its patients, consulting
3
, contracts or medical directorship, office and equipment leases with entities to which the
physician refers, soliciting and excepting or offering any gift or gratuity for more than nomi-
nal value to or from those who may benefit from the physician practice referral
What are the recommended record retention guidelines? - ANSWER The length of time
that a practice records are to be retained specified in the standards and procedures based
on federal and state statute should be consulted, medical records if in the possession of
practice need to be secured against loss distruction, unauthorized access, reproduction cor-
ruption or damage, standards and procedures can stipulate the disposition of the medical
records in the event the practice is sold or closed
What is the importance of compliance training? - ANSWER 1) all employees will receive
training on how to perform their jobs in compliance with standards and practices in any ap-
plicable regulations, 2) each employee will understand the compliance is a condition of con-
tinued employment 3) compliance training focuses on explaining why the practice is devel-
oping a compliance program
What should be included in billing and coding training? - ANSWER Coding requirements,
clean development and submission process, signing a form for a physician without physician
authorization, proper documentation of services rendered, proper billing standards and pro-
cedures for submission to accurate bill for services to federal healthcare program beneficiar-
ies, the legal sanctions for submitting deliberate false a reckless billings
What steps are required to responding to detected offenses? - ANSWER Corrective action
plan, the return of any overpayments, a report to the government, and or a referral for law-
enforcement authorities
A compliance program's open communication should include the following: - ANSWER
The requirement employees conduct themselves in good faith, and report anything to be
fraudulent . The creation of user-friendly (such drop box for larger practices) for effectively
reporting conduct; Provisions procedures that state that failure report erroneous or fraudu-
lent conduct. compliance development of a simple and readily accessible procedure to pro-
cess fraudulent conduct; billing company is used, communication to and from the billing
company's compliance officer/contact and other responsible staff to coordinate billing and
compliance activities.
4
original anti-kickback legislation the legislation stated the statute was to prevent fraud and
abuse from federal healthcare programs. A criminal statute that provides exchange of any-
thing of value in an effort to induce or reward the referral of federal healthcare program
business. If fined up to $25,000 and imprisonment up to five years
Safe harbors under anti-kickback statute? - ANSWER Safe harbors immunize certain pay-
ments and business practices that are implicated by the anti-kickback statute from criminal
and civil prosecution under the statute to be protected in a safe harbor and arrangement
must fit squarely in the safe harbor
Examples of safe harbors - ANSWER Safe harbors include investments in ambulatory sur-
gical centers, joint ventures in underserved areas, practitioner recruitment in underserved
areas, sales a physician practices to hospitals in underserved areas, subsidiaries for obstetri-
cal malpractice insurance in underserved areas, investment in group practices, specialty re-
ferral arrangements between providers, cooperative the hospital service organizations
Seven elements of program for individual and small group physician practices - ANSWER
The seven elements are conducting internal monitoring and auditing, implementing compli-
ance and practice standards, designating a compliance officer or contact, conducting appro-
priate training and education, responding appropriately to detected offenses and developing
corrective action, developing open lines of communication, and enforcing disciplinary stand-
ards through well-publicized guidelines
Benefits of a voluntary compliance program - ANSWER Speed and optimize proper pay-
ment of claims, minimize mistakes, reduce the chances that an audit will be conducted by
HCFA or that OIG and, avoid conflicts with the self referral and anti-kickback statute
1
,Difference between erroneous and fraudulent claims to federal healthcare programs - AN-
SWER Fraudulent claims intentionally or recklessly are submitted to federal healthcare
programs. Erroneous claims are innocent errors submitted unintentionally to federal
healthcare programs
What responsibility do healthcare providers have to federal healthcare programs? - AN-
SWER Federal healthcare providers have a duty to reasonably ensure that the claim sub-
mitted to Medicare and other federal healthcare programs are true and accurate
What are the steps for auditing and monitoring evaluations - ANSWER Ensure that the
standards and procedures are in fact current and accurate but also whether the compliance
program is working. following steps a standards and procedures review and claim submis-
sion audit
What do you validate reviewing policies and procedures? - ANSWER Validate they are
current and accurate if standards and procedures are found to be ineffective or outdated
they should be updated to reflect changes in government regulations or compendiums gen-
erally relied upon by physicians and insurance for example CPT and ICD-10 codes
Who should be involved in a claim submission audit? - ANSWER The person in charge of
billing and a medically trained person to audit the records
What should physicians practice do if they are using another entities compliance materials? -
ANSWER They need to tailor the materials to be applied by the physician practice starting
by the following, 1) develop written standards and procedures 2) updating clinical forms 3)
make sure they facilitate encouraging clear and complete documentation of patient care
What are the four basic risk areas developed by the OIG? - ANSWER 1) coding and billing
2) reasonable and necessary services 3) documentation 4) improper inducements
What are the biggest risks with coding and billing? - ANSWER Billing for services not ren-
dered or provided by as claimed, submitting claims for equipment medical supplies and ser-
vices that are not reasonable and necessary, double billing resulting in duplicate payments,
2
,billing for noncovered services as if covered, knowing misuse of a provider identification
numbers which results in improper billing, unbundling billing for each component of service
instead of billing for all inclusive code, failure to properly use Coding modifiers, and a coding
the level of service provided
What are the risks with the physician documentation? - ANSWER The risks are documen-
tation is not performed timely and accurate. it is incomplete, it does not reflect appropriate
documentation of the diagnosis and treatment plan
What are examples of internal documentation guidelines a practice could use? - ANSWER
Examples of internal documentation guidelines are the medical record is complete and legi-
ble, the documentation for each patient encounter includes the reason for the encounter
any relative history, physical examination, findings prior to diagnostic test results, assess-
ment clinical impression or diagnosis plan of care and date of legible Identity of the other
observer
What is one method for improving quality in documentation? - ANSWER The method is
to compare the practices claim denial rate to the rates of other practices in the same spe-
cialty to the extent of the practice can obtain that information from the carrier. Physician
coding and diagnoses distribution can be compared for each physician with the same spe-
cialty to identify variances.
What are areas to monitor for that HCFA 1500 form? - ANSWER Linking the diagnosis
code to the visit service, use of modifiers appropriately, provide Medicare with all infor-
mation about beneficiaries other insurance coverage under Medicare secondary payer pol-
icy, improper inducements kickbacks and self referrals
Improper Inducements , Kickbacks and Self-Referrals. - ANSWER Remuneration for refer-
rals is illegal because it can distort medical decision-making, cause overutilization of services
or supplies, increase costs to Federal health care
Areas to consider for improper inducements? - ANSWER Financial arrangements with
outside entities to home practice may refer federal healthcare program business, joint ven-
tures with entity supplies goods or services to physician practice or its patients, consulting
3
, contracts or medical directorship, office and equipment leases with entities to which the
physician refers, soliciting and excepting or offering any gift or gratuity for more than nomi-
nal value to or from those who may benefit from the physician practice referral
What are the recommended record retention guidelines? - ANSWER The length of time
that a practice records are to be retained specified in the standards and procedures based
on federal and state statute should be consulted, medical records if in the possession of
practice need to be secured against loss distruction, unauthorized access, reproduction cor-
ruption or damage, standards and procedures can stipulate the disposition of the medical
records in the event the practice is sold or closed
What is the importance of compliance training? - ANSWER 1) all employees will receive
training on how to perform their jobs in compliance with standards and practices in any ap-
plicable regulations, 2) each employee will understand the compliance is a condition of con-
tinued employment 3) compliance training focuses on explaining why the practice is devel-
oping a compliance program
What should be included in billing and coding training? - ANSWER Coding requirements,
clean development and submission process, signing a form for a physician without physician
authorization, proper documentation of services rendered, proper billing standards and pro-
cedures for submission to accurate bill for services to federal healthcare program beneficiar-
ies, the legal sanctions for submitting deliberate false a reckless billings
What steps are required to responding to detected offenses? - ANSWER Corrective action
plan, the return of any overpayments, a report to the government, and or a referral for law-
enforcement authorities
A compliance program's open communication should include the following: - ANSWER
The requirement employees conduct themselves in good faith, and report anything to be
fraudulent . The creation of user-friendly (such drop box for larger practices) for effectively
reporting conduct; Provisions procedures that state that failure report erroneous or fraudu-
lent conduct. compliance development of a simple and readily accessible procedure to pro-
cess fraudulent conduct; billing company is used, communication to and from the billing
company's compliance officer/contact and other responsible staff to coordinate billing and
compliance activities.
4
