HCCA CHC - Stark & Anti Kickback Exam With
Complete Solutions
AntiKickback Statute Highlights - ANSWER 1. Criminal/Civil-you go out of business
2. Any federal health program-Medicare, Medicaid, Tri-Care
3. Requires proof of improper intent-DOJ-Criminal
4. Applies to any referral source
5. 24 Safe Harbors
6. OIG Advisory Opinions
Stark Highlights - ANSWER 1. Civil only-no prison time
2. Medicare only
3. Strict Liability-does not consider knowledge or intent. If X happens, then you are held
liable regardless of intent.
4. Must be a physician and entity in the mix
5. Exceptions
6. CMS Advisory Opinions
Stark Law Enforcement - ANSWER 1. CMS
2. HHS-OIG (Does not enforce, but reviews Stark Violations to see if there is a kickback)
3. DOJ (only enforces false claims act, predicated on Stark/ Tainted Referral)
Stark Law 42 USC 1395nn - ANSWER Non-compliance period is known as the
'disallowance period." No billing of Medicare or patient during disallowance
period/non-compliance period. Any co-pays during this time also need to be returned.
, Upon determination of Stark Law non-compliance. - ANSWER place a bill-hold
immediately.
Stark prohibits - ANSWER A physician from making a referral of a Medicare Patient to an
entity that furnishes 'designated health services' (DHS) if the physician has a financial
relationship with the entity, unless an except applies.
What are Designated Health Services (DHS)? - ANSWER CMS list of HCPCS codes. For
hospitals, it includes EVERYTHING because HCPCS code of inpatient/outpatient
referrals.
Stark 3-step analysis - ANSWER 1. Is there a physician referral to a DHS?
2. Does physician (or immediate family member) have a financial relationship with the
entity providing the DHCS?
3. Does the financial relationship meet an exception? (ex: written contract in place)
Stark Sanctions - ANSWER 1. Denials (CMS denies payment for claims)
2. Refund (entity has duty to refund)
3. Civil Monetary Penalties ($15,000 for knowingly presenting or causing another to
present improper claim) ($100,000 for a scheme to circumvent the regulations)
4. Exclusion potential
5. Potential False Claims Act liability
Stark Definition: Physician - ANSWER Medical doctor, osteopathic doctor, doctor of
dental surgery or dental medicine, podiatry, a doctor of optometry or a chiropractor
Stark Definition: Immediate Family Member - ANSWER Spouse, natural or adoptive
parent, children or siblings, step-siblings, in-laws, grandparents/grandchildren.
Stark Definition: Entity - ANSWER Physicians sole practice or practice of multiple
physicians and any other person, sole proprietorship, public or private agency or trust,
Complete Solutions
AntiKickback Statute Highlights - ANSWER 1. Criminal/Civil-you go out of business
2. Any federal health program-Medicare, Medicaid, Tri-Care
3. Requires proof of improper intent-DOJ-Criminal
4. Applies to any referral source
5. 24 Safe Harbors
6. OIG Advisory Opinions
Stark Highlights - ANSWER 1. Civil only-no prison time
2. Medicare only
3. Strict Liability-does not consider knowledge or intent. If X happens, then you are held
liable regardless of intent.
4. Must be a physician and entity in the mix
5. Exceptions
6. CMS Advisory Opinions
Stark Law Enforcement - ANSWER 1. CMS
2. HHS-OIG (Does not enforce, but reviews Stark Violations to see if there is a kickback)
3. DOJ (only enforces false claims act, predicated on Stark/ Tainted Referral)
Stark Law 42 USC 1395nn - ANSWER Non-compliance period is known as the
'disallowance period." No billing of Medicare or patient during disallowance
period/non-compliance period. Any co-pays during this time also need to be returned.
, Upon determination of Stark Law non-compliance. - ANSWER place a bill-hold
immediately.
Stark prohibits - ANSWER A physician from making a referral of a Medicare Patient to an
entity that furnishes 'designated health services' (DHS) if the physician has a financial
relationship with the entity, unless an except applies.
What are Designated Health Services (DHS)? - ANSWER CMS list of HCPCS codes. For
hospitals, it includes EVERYTHING because HCPCS code of inpatient/outpatient
referrals.
Stark 3-step analysis - ANSWER 1. Is there a physician referral to a DHS?
2. Does physician (or immediate family member) have a financial relationship with the
entity providing the DHCS?
3. Does the financial relationship meet an exception? (ex: written contract in place)
Stark Sanctions - ANSWER 1. Denials (CMS denies payment for claims)
2. Refund (entity has duty to refund)
3. Civil Monetary Penalties ($15,000 for knowingly presenting or causing another to
present improper claim) ($100,000 for a scheme to circumvent the regulations)
4. Exclusion potential
5. Potential False Claims Act liability
Stark Definition: Physician - ANSWER Medical doctor, osteopathic doctor, doctor of
dental surgery or dental medicine, podiatry, a doctor of optometry or a chiropractor
Stark Definition: Immediate Family Member - ANSWER Spouse, natural or adoptive
parent, children or siblings, step-siblings, in-laws, grandparents/grandchildren.
Stark Definition: Entity - ANSWER Physicians sole practice or practice of multiple
physicians and any other person, sole proprietorship, public or private agency or trust,
