Certified Medical Coding Specialist Regulatory Frameworks & Compliance 5 — Questions and Answers
Question 1: 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?
- Stark Law
- Anti-Kickback Statute (42 USC 1320a-7b(b)) (Correct answer)
- False Claims Act
- Civil Monetary Penalties Law
Correct 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.
Question 2: 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?
- Terminate the coder immediately
- Report directly to law enforcement
- Investigate the scope of the problem internally (Correct answer)
- Recode all claims and submit corrections without investigation
Correct 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.
Question 3: Which of the following is NOT one of the OIG's seven elements of an effective compliance program?
- Written policies and procedures
- Designation of a compliance officer
- Mandatory participation in government audits (Correct answer)
- Effective lines of communication
Correct 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.
Question 4: 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?
- False Claims Act
- Anti-Kickback Statute
- Stark Law (Physician Self-Referral Law) (Correct answer)
- HIPAA Privacy Rule
Correct 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.
Question 5: Under the HIPAA Security Rule, what type of safeguard includes workforce training, security policies, and contingency planning?
- Physical safeguards
- Administrative safeguards (Correct answer)
- Technical safeguards
- Organizational safeguards
Correct answer: Administrative safeguards
Administrative safeguards under the HIPAA Security Rule encompass policies, procedures, workforce management, and contingency planning to protect ePHI.
Question 6: When CMS issues a Program for Evaluating Payment Patterns Electronic Report (PEPPER), what is its primary purpose for a hospital?
- To notify the hospital of a formal audit finding
- To provide comparative data on potentially improper billing patterns (Correct answer)
- To set new reimbursement rates for DRGs
- To identify excluded providers on the hospital's staff
Correct 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.
Question 7: A provider who is excluded from Medicare/Medicaid participation submits claims through another provider's NPI number. This scheme is an example of:
- Upcoding
- Billing under another provider's number (credit/card swapping) (Correct answer)
- Identity theft under HIPAA
- A valid reassignment of benefits
Correct 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.
Certified Medical Coding Specialist Regulatory Frameworks & Compliance 5
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?