CLC Laboratory Financial Management & Reimbursement 2

Question 1

The Anti-Kickback Statute (AKS) in the context of laboratory services prohibits:

Accepted Answer

Offering or receiving anything of value to induce test referrals for federal program patients

Answer

Laboratories from performing tests outside their CLIA scope

Answer

Physicians from ordering redundant laboratory tests

Answer

Laboratories from billing patients directly for Medicare-covered tests

Question 2

The Stark Law (Physician Self-Referral Law) primarily restricts:

Accepted Answer

Physicians with financial relationships from referring patients for designated health services, including laboratory services

Answer

Physicians from ordering tests without documented medical necessity

Answer

Laboratories from accepting referrals from non-participating physicians

Answer

Hospital-based laboratories from billing independently of the hospital

Question 3

Qui tam provisions of the False Claims Act allow:

Accepted Answer

Private individuals to file lawsuits on behalf of the government and share in financial recoveries

Answer

Medicare to audit laboratory claims retroactively for up to 10 years

Answer

Laboratories to appeal denied claims directly to federal district court

Answer

Physicians to self-report billing errors in exchange for immunity

Question 4

The OIG Work Plan is a valuable compliance tool for laboratory consultants primarily because it:

Accepted Answer

Identifies areas the Office of Inspector General is actively scrutinizing for fraud and abuse

Answer

Provides the current Medicare fee schedule for all laboratory CPT codes

Answer

Lists all CLIA-certified laboratories in the United States

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Establishes annual staffing benchmarks for clinical laboratories

Question 5

'Upcoding' in laboratory billing is defined as:

Accepted Answer

Billing for a higher-complexity or more expensive test than what was actually performed

Answer

Updating CPT codes to reflect current AMA revisions

Answer

Adding diagnosis codes to support medical necessity after the fact

Answer

Submitting duplicate claims to two different payers simultaneously

Question 6

An effective laboratory compliance program, as outlined in OIG guidance, must include:

Accepted Answer

Written policies, a compliance officer, training, internal auditing, and a confidential reporting mechanism

Answer

Annual external CLIA inspections and proficiency testing enrollment

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Only HIPAA privacy training and billing documentation requirements

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Monthly claims submission reports filed directly with CMS

Question 7

A prospective billing edit check system in a laboratory compliance program is designed to:

Accepted Answer

Identify and correct coding or coverage errors before claims are submitted to payers

Answer

Recover overpayments identified during post-payment audits

Answer

Monitor physician ordering patterns for potential over-utilization

Answer

Audit CLIA test performance records against billing records