Laboratory Financial Management & Reimbursement Flashcards
7 cards from real CLC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Laboratory Financial Management & Reimbursement flashcards as text
The Anti-Kickback Statute (AKS) in the context of laboratory services prohibits:
Answer: Offering or receiving anything of value to induce test referrals for federal program patients
The AKS makes it a criminal offense to offer, pay, solicit, or receive remuneration to induce referrals of items or services covered by federal healthcare programs, including laboratory tests.
The Stark Law (Physician Self-Referral Law) primarily restricts:
Answer: Physicians with financial relationships from referring patients for designated health services, including laboratory services
The Stark Law prohibits physicians who have a financial relationship with an entity from referring Medicare/Medicaid patients to that entity for designated health services including clinical laboratory services, unless a specific exception applies.
Qui tam provisions of the False Claims Act allow:
Answer: Private individuals to file lawsuits on behalf of the government and share in financial recoveries
Qui tam provisions empower private individuals (relators/whistleblowers) to file suit on the government's behalf and receive 15–30% of any recovered funds.
The OIG Work Plan is a valuable compliance tool for laboratory consultants primarily because it:
Answer: Identifies areas the Office of Inspector General is actively scrutinizing for fraud and abuse
The OIG Work Plan describes planned and ongoing reviews, audits, and investigations, alerting laboratories to the compliance risk areas receiving current government attention.
'Upcoding' in laboratory billing is defined as:
Answer: Billing for a higher-complexity or more expensive test than what was actually performed
Upcoding involves intentionally billing a service at a higher code level than performed, resulting in higher reimbursement and constituting healthcare fraud.
An effective laboratory compliance program, as outlined in OIG guidance, must include:
Answer: Written policies, a compliance officer, training, internal auditing, and a confidential reporting mechanism
The OIG's seven elements of an effective compliance program include written standards, a compliance officer, training, communication channels, auditing, discipline enforcement, and corrective action procedures.
A prospective billing edit check system in a laboratory compliance program is designed to:
Answer: Identify and correct coding or coverage errors before claims are submitted to payers
Prospective edit checks catch errors prior to claim submission, preventing improper payments and reducing exposure to audits and recoupment demands.