Regulatory Compliance & Risk Management Flashcards

Under HIPAA's Minimum Necessary Standard, a dental consultant reviewing a claim should request:

Answer: Only the information reasonably necessary to accomplish the review purpose

HIPAA's Minimum Necessary Standard requires covered entities to limit PHI requests to what is reasonably needed for the specific purpose.

A dental plan's internal audit reveals a pattern of upcoding by a network provider. Under the False Claims Act, which party bears primary liability if the plan knowingly paid those claims?

Answer: Both the provider and the plan may face liability if the plan knowingly paid false claims

The FCA can reach any entity that knowingly presents or causes to present a false claim, including payers that knowingly pay them.

Which federal regulation governs the coordination of benefits (COB) when a patient is covered by both a group dental plan and Medicare?

Answer: Medicare Secondary Payer (MSP) rules

Medicare Secondary Payer rules establish which payer is primary when Medicare and an employer group health plan both cover a patient.

A dental consultant identifies that a practice is billing crown preps and final crowns on the same tooth on the same date of service. This is an example of:

Answer: Unbundling of a global procedure

Billing separately for components that are part of a single comprehensive procedure constitutes unbundling, which is a form of fraudulent billing.

The Stark Law (physician self-referral law) as applied to dentistry primarily concerns:

Answer: Dental referrals tied to designated health services under Medicare/Medicaid with financial relationships

Stark Law prohibits physician (and applicable provider) self-referrals for designated health services when a financial relationship exists, with relevance to dental services covered under Medicare/Medicaid.

When a dental plan receives a subpoena for a member's claim records during litigation, the plan's FIRST step should be:

Answer: Notify the member and consult legal counsel before releasing PHI

HIPAA permits disclosure under a subpoena only with specific procedural protections, and legal counsel should guide the response process.

A state prompt-pay law requires insurers to pay clean dental claims within 30 days or pay interest. If a plan's utilization review delay causes a clean claim to go unpaid for 45 days, the consultant should advise:

Answer: The plan likely owes interest and should review its UR turnaround times for compliance

UR delays that extend payment beyond state prompt-pay deadlines generally trigger interest obligations for fully insured plans; consultants should flag systemic UR bottlenecks.