CDC Regulatory Compliance & Risk Management 2 — Questions and Answers
Question 1: Under HIPAA's Minimum Necessary Standard, a dental consultant reviewing a claim should request:
- The patient's complete lifetime dental and medical history
- Only the information reasonably necessary to accomplish the review purpose (Correct answer)
- All records held by every provider the patient has visited
- Full demographic and financial data in addition to clinical records
Correct 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.
Question 2: 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?
- Only the submitting provider bears liability
- Both the provider and the plan may face liability if the plan knowingly paid false claims (Correct answer)
- Liability is limited to plan administrators personally
- No liability exists if the plan later recoups the overpayment
Correct 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.
Question 3: Which federal regulation governs the coordination of benefits (COB) when a patient is covered by both a group dental plan and Medicare?
- ERISA Section 502
- Medicare Secondary Payer (MSP) rules (Correct answer)
- ADA Code of Professional Conduct
- COBRA continuation coverage rules
Correct 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.
Question 4: 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:
- Appropriate staging of treatment
- Unbundling of a global procedure (Correct answer)
- Legitimate dual-coding
- Coordination of benefits fraud
Correct 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.
Question 5: The Stark Law (physician self-referral law) as applied to dentistry primarily concerns:
- Any dental practice that refers patients to its own in-house lab for designations
- Dental referrals tied to designated health services under Medicare/Medicaid with financial relationships (Correct answer)
- All in-network referrals regardless of payer source
- Medicaid dental referrals only when the provider is a general dentist
Correct 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.
Question 6: When a dental plan receives a subpoena for a member's claim records during litigation, the plan's FIRST step should be:
- Immediately produce all requested records to avoid contempt
- Notify the member and consult legal counsel before releasing PHI (Correct answer)
- Destroy records that could be harmful to the plan's position
- Transfer the subpoena directly to the treating dentist
Correct 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.
Question 7: 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:
- The delay is permissible because UR reviews are excluded from prompt-pay statutes
- The plan likely owes interest and should review its UR turnaround times for compliance (Correct answer)
- The provider must resubmit the claim to restart the clock
- State prompt-pay laws do not apply to self-funded ERISA plans regardless of state
Correct 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.
CDC Regulatory Compliance & Risk Management 2
Under HIPAA's Minimum Necessary Standard, a dental consultant reviewing a claim should request: