ABFM Industry Regulations 3 — Questions and Answers
Question 1: Under the Medicare Access and CHIP Reauthorization Act (MACRA), the Quality Payment Program (QPP) offers two participation pathways. Which of the following is NOT one of those pathways?
- Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
- Accountable Care Organization Shared Savings Program (MSSP) (Correct answer)
- Both MIPS and APMs are the two pathways
Correct answer: Accountable Care Organization Shared Savings Program (MSSP)
MACRA's QPP offers two pathways: MIPS and Advanced APMs; the Medicare Shared Savings Program is a type of APM but is not itself one of the two main QPP tracks.
Question 2: The Office for Civil Rights (OCR) may impose HIPAA civil monetary penalties on a covered entity that had no knowledge of a violation and could not have known with reasonable diligence. Which penalty tier applies?
- $100–$50,000 per violation, up to $25,000 per year (Correct answer)
- $1,000–$50,000 per violation, up to $100,000 per year
- $10,000–$50,000 per violation, up to $250,000 per year
- $50,000 per violation, up to $1.5 million per year
Correct answer: $100–$50,000 per violation, up to $25,000 per year
The lowest HIPAA penalty tier ($100–$50,000 per violation, annual cap $25,000) applies when the covered entity did not know and could not reasonably have known of the violation.
Question 3: Which of the following is a key requirement under the CMS Promoting Interoperability (PI) program for eligible professionals?
- Submission of paper claims only
- Demonstrating meaningful use of certified electronic health record technology (Correct answer)
- Maintaining a minimum patient panel of 2,000 patients
- Annual attestation of board certification status
Correct answer: Demonstrating meaningful use of certified electronic health record technology
The PI program (formerly Meaningful Use) requires eligible professionals to demonstrate meaningful use of certified EHR technology to receive incentive payments or avoid Medicare payment adjustments.
Question 4: A patient requests an amendment to their medical record under HIPAA. The covered entity may deny the request if:
- The record contains information that could harm the patient
- The record was not created by the covered entity (Correct answer)
- The patient has not paid outstanding balances
- The information is older than 7 years
Correct answer: The record was not created by the covered entity
A covered entity may deny an amendment request if it did not create the record, unless the originating entity is no longer available.
Question 5: Under the Ryan Haight Online Pharmacy Consumer Protection Act, prescribing controlled substances via telemedicine without a prior in-person evaluation is generally:
- Permitted if the patient provides informed consent electronically
- Prohibited unless specific DEA exceptions or waivers apply (Correct answer)
- Allowed for Schedule III–V controlled substances only
- Permitted if the physician is licensed in both states
Correct answer: Prohibited unless specific DEA exceptions or waivers apply
The Ryan Haight Act generally requires an in-person evaluation before prescribing controlled substances via telemedicine, with limited exceptions such as DEA-registered telemedicine practitioners.
Question 6: The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals with emergency departments to provide:
- Free care to all uninsured patients regardless of diagnosis
- A medical screening examination and stabilization to all patients, regardless of ability to pay (Correct answer)
- Specialist consultations within 30 minutes of ED arrival
- Transfer to a tertiary center for all critical patients
Correct answer: A medical screening examination and stabilization to all patients, regardless of ability to pay
EMTALA mandates that any individual presenting to an ED receive a medical screening examination and necessary stabilizing treatment regardless of insurance status or ability to pay.
Question 7: Which of the following actions constitutes 'upcoding' under the False Claims Act?
- Billing for a complex E&M visit when only a brief visit was performed (Correct answer)
- Using a secondary diagnosis code to support medical necessity
- Appending a modifier to an evaluation and management code
- Submitting claims electronically rather than on paper
Correct answer: Billing for a complex E&M visit when only a brief visit was performed
Upcoding means billing a higher-level service than was actually provided, which violates the False Claims Act and constitutes Medicare/Medicaid fraud.
ABFM Industry Regulations 3
Under the Medicare Access and CHIP Reauthorization Act (MACRA), the Quality Payment Program (QPP) offers two participation pathways.
Which of the following is NOT one of those pathways?