Compliance & Regulatory Requirements Flashcards

The 'safe harbor' provisions under the Anti-Kickback Statute protect certain arrangements by:

Answer: Defining specific payment and business practices that will not be treated as violations

Safe harbors under the AKS specify types of financial arrangements that meet strict criteria and are therefore shielded from prosecution, even though they might otherwise appear to violate the statute.

Under the Genetic Information Nondiscrimination Act (GINA), health insurers are prohibited from:

Answer: Using genetic information to make eligibility, coverage, underwriting, or premium-setting decisions

GINA Title I prohibits health insurers from using genetic information for underwriting purposes, including setting premiums, eligibility determinations, or coverage decisions.

A healthcare administrative professional discovers that a billing coder submitted claims with upcoded procedure codes. The appropriate first action is to:

Answer: Report the finding through the organization's compliance reporting mechanism

Suspected fraudulent billing should first be reported internally through the compliance program's reporting process, which will then trigger an investigation.

The '72-hour rule' under Medicare requires that outpatient services provided within 72 hours of an inpatient admission be:

Answer: Bundled into the inpatient prospective payment system (IPPS) payment

Medicare's 72-hour rule requires that outpatient diagnostic and related therapeutic services rendered within 72 hours before an inpatient admission be bundled into the inpatient DRG payment.

Which element is required in every valid HIPAA-compliant authorization for use or disclosure of PHI?

Answer: A description of the information to be used or disclosed and the purpose

A valid HIPAA authorization must include a description of the PHI to be disclosed and the purpose of the use or disclosure, along with other required core elements.

The Medicare Fraud Prevention and Enforcement Action Team (HEAT) initiative was established primarily to:

Answer: Strengthen coordination between HHS and DOJ to prevent and prosecute healthcare fraud

HEAT was created to enhance collaboration between HHS and DOJ to combat Medicare and Medicaid fraud through coordinated enforcement actions and Strike Force teams.

When a healthcare organization identifies a potential overpayment from Medicare, the Affordable Care Act requires the overpayment to be reported and returned within:

Answer: 60-day period after the overpayment is identified

The ACA's '60-day rule' requires providers to report and return identified Medicare or Medicaid overpayments within 60 days of identification or the date a corresponding cost report is due.