AHFI Exam Questions And Answers 100%
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Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - answerProhibits 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-...
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
Anti-Kickback Statute (42 US SS 1320a-7b (b) - answer✔Any items or services
Anti-Kickback Statute (42 US SS 1320a-7b (b) (Intent) - answer✔Intent MUST be proven
(knowing and willful)
Anti-Kickback Statute (42 US SS 1320a-7b (b) Criminal penalties - answer✔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) - 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.
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