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
Which federal statute makes it illegal to knowingly and willfully offer, pay, solicit, or receive anything of value to induce or reward referrals of items or services covered by federal healthcare programs?
Answer: Anti-Kickback Statute (42 USC 1320a-7b(b))
The Anti-Kickback Statute is a criminal statute that prohibits offering, paying, soliciting, or receiving remuneration to induce or reward federal healthcare program referrals.
A compliance officer discovers that a coder has been miscoding diagnoses to meet LCD requirements. What is the FIRST required action under a robust compliance program?
Answer: Investigate the scope of the problem internally
A compliance program requires a thorough internal investigation to determine the scope, root cause, and whether it was systemic before corrective actions are taken.
Which of the following is NOT one of the OIG's seven elements of an effective compliance program?
Answer: Mandatory participation in government audits
Mandatory audit participation is not one of the seven OIG compliance elements; the seven elements focus on internal program structure, education, and self-governance.
A physician refers a patient to a physical therapy clinic in which the physician has a direct financial interest. Which law is MOST likely violated?
Answer: Stark Law (Physician Self-Referral Law)
Stark Law prohibits physician self-referrals for designated health services (including physical therapy) to entities in which the physician has a financial relationship, absent an exception.
Under the HIPAA Security Rule, what type of safeguard includes workforce training, security policies, and contingency planning?
Answer: Administrative safeguards
Administrative safeguards under the HIPAA Security Rule encompass policies, procedures, workforce management, and contingency planning to protect ePHI.
When CMS issues a Program for Evaluating Payment Patterns Electronic Report (PEPPER), what is its primary purpose for a hospital?
Answer: To provide comparative data on potentially improper billing patterns
PEPPER provides hospitals with Medicare claims data statistics showing where their billing patterns fall compared to national and jurisdiction peers, helping identify compliance risk areas.
A provider who is excluded from Medicare/Medicaid participation submits claims through another provider's NPI number. This scheme is an example of:
Answer: Billing under another provider's number (credit/card swapping)
Submitting claims under another provider's NPI to circumvent exclusion is a serious fraud scheme that violates both the FCA and AKS and may constitute identity fraud.