CDIP Healthcare Compliance and Ethics 3 — Questions and Answers
Question 1: Which federal agency is primarily responsible for investigating healthcare fraud and abuse under the Medicare and Medicaid programs?
- Office of Inspector General (OIG) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- Department of Justice (DOJ)
- Office for Civil Rights (OCR)
Correct answer: Office of Inspector General (OIG)
The OIG is the primary federal agency responsible for investigating healthcare fraud, waste, and abuse in federal health programs.
Question 2: What is the purpose of the OIG's Work Plan in relation to CDI and coding compliance?
- It identifies areas of focus for audits and investigations that coders and CDI specialists should prioritize for compliance review (Correct answer)
- It provides mandatory coding guidelines that supersede ICD-10-CM Official Guidelines
- It lists all hospitals under active fraud investigation
- It establishes maximum reimbursement rates for DRG codes
Correct answer: It identifies areas of focus for audits and investigations that coders and CDI specialists should prioritize for compliance review
The OIG Work Plan identifies audit targets and areas of concern, helping compliance programs proactively assess and mitigate risk.
Question 3: Under HIPAA, a covered entity experiences a breach affecting 600 patients. What notification is required?
- Notify affected individuals, HHS, and prominent media outlets in the affected state (Correct answer)
- Notify only the affected individuals within 60 days
- Notify HHS immediately but delay patient notification until investigation is complete
- No notification is required if the breach was accidental
Correct answer: Notify affected individuals, HHS, and prominent media outlets in the affected state
For breaches affecting 500 or more residents of a state, HIPAA requires notification to affected individuals, HHS, and prominent media outlets in that state.
Question 4: A CDI specialist is asked by a physician to add a diagnosis to a record to justify a procedure already performed. What is the ethical obligation?
- Refuse the request and explain that documentation must reflect the actual clinical circumstances (Correct answer)
- Add the diagnosis if the physician insists, as they have clinical authority
- Consult the billing department before making a decision
- Add the diagnosis only if it improves the patient's DRG
Correct answer: Refuse the request and explain that documentation must reflect the actual clinical circumstances
CDI professionals must refuse requests to add unsupported diagnoses, as doing so would constitute falsification of medical records and potential fraud.
Question 5: What is the 'exclusion' penalty that the OIG can impose on healthcare providers found guilty of fraud?
- Prohibition from participating in federal healthcare programs such as Medicare and Medicaid (Correct answer)
- Suspension of medical license at the state level
- A mandatory prison sentence of up to 10 years
- Revocation of hospital accreditation by The Joint Commission
Correct answer: Prohibition from participating in federal healthcare programs such as Medicare and Medicaid
OIG exclusion bars a provider from participating in Medicare, Medicaid, and other federal healthcare programs, effectively ending their ability to receive federal reimbursement.
Question 6: Which documentation practice violates the prohibition against 'cloning' in electronic health records?
- Copying and pasting prior notes without updating them to reflect the current patient encounter (Correct answer)
- Using structured templates with required fields for each visit type
- Documenting vital signs automatically from monitoring equipment
- Using voice recognition software to transcribe physician dictation
Correct answer: Copying and pasting prior notes without updating them to reflect the current patient encounter
Cloning occurs when documentation from a prior encounter is copied forward without being updated, creating inaccurate and potentially fraudulent records.
Question 7: The principle of 'nonmaleficence' in healthcare ethics is best described as:
- The obligation to avoid causing harm to patients (Correct answer)
- The duty to promote the patient's well-being
- Respecting the patient's right to make their own decisions
- Treating patients fairly and equitably regardless of ability to pay
Correct answer: The obligation to avoid causing harm to patients
Nonmaleficence is the ethical obligation to 'do no harm,' avoiding actions that cause unnecessary injury or risk to patients.
CDIP Healthcare Compliance and Ethics 3
Which federal agency is primarily responsible for investigating healthcare fraud and abuse under the Medicare and Medicaid programs?