CPMA Exam Preparation - AAPC
嚜澧PMA Exam Preparation
Chapter 1
Compliance and
Regulatory Control
1
Compliance and Regulatory Control
? OIG 每 Protect HHS from themselves and
providers
? Compliance
每 Currently not required by OIG
? Recommended to
每 Reduce fines and penalties
每 Increase operational efficiency
每 Increase overall compliance
Compliance and Regulatory Control
Compliance plan includes:
每 7 key compliance elements per the OIG
每 Mandatory staff education
每 Disciplinary policy and procedures
2
Compliance and Regulatory Control
Compliance plan should differentiate fraud and
abuse.
每 Fraud - Intentional deception made for personal
gain
每 Abuse - Act that results in unnescessary
reimbursement without defined intent
Compliance and Regulatory Control
The OIG does impose ※self-inflicted§ audits of
HHS.
?Audits HHS programs and contracts
?Review for abuse and waste
?Performed by OAS
每Internal Staff
每Independent Resources
3
Compliance and Regulatory Control
Improper payments
每 Identify
每 Report within compliance manual
每 Establish plan of action
每 Suspend billing of only the identified service
until plan is in place and all parties educated
Compliance and Regulatory Control
Anti-kickback law prohibits:
每 Knowing and willful solicitation
每 Offer, payment or receipt in return for referring an
individual, purchase or arrangement for an item of
service
每 Examples
?
?
?
?
Bribery
Kickbacks
Offer solicit receive payment
Safe harbor provisions
4
Compliance and Regulatory Control
False Claims Act
每 Claim submitted which portrays false services
? Never performed but billed
? Disguised service
? Disguised provider
每 Civil False Claims Act
每 Criminal False Claims Act
每 Medicare/Medicaid False Claims Act
Compliance and Regulatory Control
? Provider Deficiencies
每 Self Disclosure
? 30 days
每 Appeal Rights
? ALJ appeal
? Appeal of the ALJ decision
5
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