AHFI Exam Anti-Kickback Sta tute (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 penal ties 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 applie s 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 fina ncial 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 phy sician 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 3 x 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 claim s 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 Serv ice 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 h igh level of payment error.
specific prepayment review only when there is the likelihood of sustained or h igh level of payment error.
