Compliance, Ethics, & Legal Considerations Flashcards

Under HIPAA, which action constitutes a 'minimum necessary' violation when dental staff access patient records?

Answer: A receptionist accessing full clinical notes to confirm tomorrow's appointments

HIPAA's minimum necessary standard requires staff to access only the PHI needed for their specific job function; a receptionist needs scheduling info, not full clinical notes.

A dental office receives a subpoena for a patient's records. What is the FIRST step the office should take?

Answer: Notify the patient and consult the office attorney before releasing records

A subpoena alone (without a court order) generally requires patient notice and an opportunity to object, so legal counsel should be consulted before releasing records.

Which federal law specifically prohibits physicians and dentists who have a financial relationship with an entity from referring Medicare/Medicaid patients to that entity for designated health services?

Answer: Stark Law (Physician Self-Referral Law)

The Stark Law prohibits self-referrals to entities in which the referring provider has a financial interest for certain designated health services billed to federal programs.

A dental office administrator discovers a colleague has been billing for services not rendered to increase the practice's revenue. Under the False Claims Act, what should the administrator do?

Answer: Submit a qui tam lawsuit on behalf of the government to recover damages

The False Claims Act's qui tam provisions allow a private individual (whistleblower) to file a lawsuit on behalf of the government and potentially receive a portion of the recovery.

When a dental patient requests an amendment to their health record under HIPAA, the covered entity may deny the request if:

Answer: The record was not created by the covered entity receiving the request

HIPAA permits denial of an amendment request when the covered entity did not create the information and the originating entity is available to respond.

Which of the following best describes 'unbundling' in dental coding compliance?

Answer: Billing separately for procedures that should be reported with one comprehensive code

Unbundling means reporting individual component procedures with separate codes when a single comprehensive CDT code exists that covers all components, inflating reimbursement.

A dental coder notices the dentist documented 'simple extraction' but the claim was submitted with the code for a surgical extraction. This is an example of:

Answer: Upcoding

Upcoding occurs when a higher-complexity or higher-paying procedure code is billed than the service documented in the patient's record.