Healthcare Compliance and Ethics Flashcards
7 cards from real CDIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Compliance and Ethics flashcards as text
Which federal law created the Healthcare Fraud Prevention and Enforcement Action Team (HEAT) initiative?
Answer: The Affordable Care Act (ACA)
The Affordable Care Act of 2010 strengthened anti-fraud provisions and supported the HEAT initiative as a joint DOJ-HHS enforcement effort.
A hospital's CDI program improves its case mix index (CMI) by 0.15 over one year. What is the MOST important factor that validates this improvement is compliance-driven rather than fraudulent?
Answer: The improvement is supported by concurrent documentation of clinical indicators in the medical records
Legitimate CMI improvement must be supported by documented clinical evidence in the medical record; improvement without supporting documentation suggests upcoding.
Under the Anti-Kickback Statute safe harbors, which of the following arrangements is generally PROTECTED from prosecution?
Answer: A properly structured personal services arrangement with fair market value compensation between a hospital and physician
The personal services safe harbor protects compensation arrangements that are at fair market value, do not vary based on referral volume, and meet other regulatory requirements.
What is the significance of the 'reasonable and necessary' requirement in Medicare coverage determinations for CDI professionals?
Answer: Documentation must support that the services provided were medically necessary and appropriate for the patient's condition to justify billing
Medicare only reimburses services that are reasonable and necessary, requiring documentation to clearly support the medical necessity of care provided.
An effective healthcare compliance program, as outlined by the OIG, must include which of the following seven elements?
Answer: Written policies and procedures, designated compliance officer, effective training, open communication lines, internal auditing, enforcement, and prompt response to detected offenses
The OIG's seven elements of an effective compliance program include written standards, a compliance officer, training, communication, monitoring, enforcement, and corrective action.
When a Recovery Audit Contractor (RAC) issues a demand letter for repayment of an overpayment, what is the initial timeframe a provider has to request a redetermination?
Answer: 120 days from the date of the initial determination
Providers have 120 days from the date of the initial determination to file a redetermination request, which is the first level of the Medicare appeals process.
Which ethical concept requires CDI professionals to handle patient information with discretion and share it only with authorized individuals involved in the patient's care?
Answer: Confidentiality
Confidentiality obligates healthcare professionals to protect patient information from unauthorized disclosure, forming the ethical basis of HIPAA privacy protections.