CDIP Healthcare Compliance and Ethics 3

Question 1

Which federal agency is primarily responsible for investigating healthcare fraud and abuse under the Medicare and Medicaid programs?

Accepted Answer

Office of Inspector General (OIG)

Answer

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?

Accepted Answer

It identifies areas of focus for audits and investigations that coders and CDI specialists should prioritize for compliance review

Answer

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?

Accepted Answer

Notify affected individuals, HHS, and prominent media outlets in the affected state

Answer

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?

Accepted Answer

Refuse the request and explain that documentation must reflect the actual clinical circumstances

Answer

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?

Accepted Answer

Prohibition from participating in federal healthcare programs such as Medicare and Medicaid

Answer

OIG exclusion bars a provider from participating in Medicare, Medicaid, and other federal healthcare programs, effectively ending their ability to receive federal reimbursement.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Healthcare Compliance and Ethics 3