Laws and Statutes
What are Whistleblower protections under the Federal Claims Act?
Whistleblowers can receive rewards for reporting fraud, and they are fully protected from retaliation.
What is deliberate misrepresentation of information to gain unauthorized benefits called?
Fraud
If you spot something questionable that could be fraud waste or abuse, what should you do?
Report to your supervisor immediately
True or False
Andy's license can be suspended or placed on probation.
True
This act makes it illegal to knowingly submit false claims or statements to obtain federal healthcare funds.
False Claims Act (FCA)
What results from inefficiencies, overuse, or poor management. It may not be intentional, but it drains valuable resources.
Waste
A staff member makes a documentation error but immediately reports it and corrects the claim.
Is this an example of fraud, waste, abuse, or none?
None!
Why: The staff member took action, reported it, and edited the claim to reflect accurate billing.
What are Andy's credentials and what do all those letters stand for?
Master of Arts, Licensed Professional Clinical Counselor (MA, LPCC)
This law allows for substantial fines against violations involving fraudulent billing, kickbacks, or employing excluded individuals.
Civil Monetary Penalties Law
Involves practices inconsistent with sound medical or business practices that raise healthcare costs, even without clear intent.
A therapist schedules 60-minute individual therapy sessions back-to-back all day. Multiple clients report that sessions regularly last 25–30 minutes. Documentation consistently reflects full 60-minute sessions, with minimal detail and identical language across notes. The therapist explains that they are “very efficient” and can provide effective therapy in less time.
Is this an example of fraud, waste, abuse, or none?
Fraud
Why: Billing for time not actually provided and documenting falsely to support that billing is intentional misrepresentation.
What could occur at Alliance in the event that Andy's license is suspended, revoked, or placed on probation?
Alliance would not be able to bill for mental health services :(
Alliance would need to find a new licensed individual to bill under :(
This statute prohibits any payment or reward in exchange for patient referrals or healthcare services covered by federal programs such as Medicare or Medicaid.
Anti-Kickback Statute (AKS)
Safeguarding your login credentials, verifying billing accuracy, and diligently documenting are all examples of?
Prevention
A client has been stable for several months and is consistently meeting their treatment goals. Despite this, services continue at the same high frequency because it is easier to keep the schedule the same and the service is still authorized. Sessions often focus on reviewing information the client already understands, with little new skill development or clinical need identified. No changes are made to the treatment plan or service frequency.
Is this an example of fraud, waste, abuse, or none?
Waste
Why: Services are being overused without clinical necessity. There is no intent to deceive, but resources are being spent on care that is no longer needed or effective.
How do Alliance Supervisors attempt to detect FWA?
Client satisfaction surveys, approving and signing off on documentation, and scorecard numbers.
FWA violations can lead to... (3 answers)
Substantial fines, program exclusions, and criminal charges.
The act of complying with federal, state, or local laws and regulations in the workplace.
Compliance
A provider delivers an ongoing mental health service to a client and bills appropriately for sessions. However, each visit looks nearly identical: the same activities are used every time, no adjustments are made based on the client’s progress, and the service continues for months without updating goals or changing interventions. The client reports they feel “stuck” and unsure what they are working toward, but services continue at the same frequency because they are approved.
Is this an example of fraud, waste, abuse, or none?
Abuse
Why: While services are authorized and actually provided, continuing a service without adapting it to the client’s needs or progress is inconsistent with program expectations and results in unnecessary use of resources. This is not intentional deception (fraud), but it misuses the benefit.
What does Andy need to complete on a yearly basis to maintain his license?
Complete Continuing Education Units (CEUs)
Complete forms demonstrating that he remains able to complete duties as a MHP.