Regulatory Frameworks & Compliance Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory Frameworks & Compliance flashcards as text
The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring patients for designated health services to entities in which they have a financial relationship UNLESS:
Answer: A valid Stark Law exception applies
Stark Law is a strict liability statute, meaning intent is irrelevant, but numerous statutory and regulatory exceptions permit otherwise-prohibited arrangements.
Which compliance program element requires organizations to establish mechanisms for employees to report suspected violations confidentially?
Answer: Open lines of communication (hotlines)
The OIG's seven compliance program elements include open lines of communication, such as anonymous hotlines, so employees can report concerns without fear of retaliation.
A coder assigns a code for a higher-complexity procedure than what was actually performed to increase reimbursement. This is an example of:
Answer: Upcoding
Upcoding involves billing for a more expensive service or higher-level code than what was actually provided or documented.
Under the OIG's Corporate Integrity Agreement (CIA), a healthcare organization typically must do all of the following EXCEPT:
Answer: Cease all Medicare/Medicaid billing for 5 years
A CIA allows organizations to continue participating in federal healthcare programs while implementing specific compliance obligations; it does not require cessation of billing.
Which type of Medicare audit involves a statistical sample of claims and extrapolates the error rate to a universe of claims to calculate an overpayment?
Answer: Statistical sampling extrapolation audit
Statistical sampling extrapolation is used by CMS and its contractors to estimate total overpayments based on a statistically valid sample of claims.
Which regulation requires Medicare providers to report and return identified overpayments within 60 days of identification?
Answer: The 60-Day Rule (42 CFR Part 401)
The 60-Day Rule, codified at 42 CFR Part 401, requires Medicare and Medicaid providers to report and return identified overpayments within 60 days, or they may face FCA liability.
A provider bills for 10 units of a service but only delivered 6 units. This billing practice is known as:
Answer: Billing for services not rendered
Billing for more units or services than were actually provided constitutes billing for services not rendered, a form of healthcare fraud.