Compliance & Regulatory Knowledge Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliance & Regulatory Knowledge flashcards as text
A hospital bills Medicare for an inpatient admission that a RAC auditor later determines should have been billed as outpatient observation. This is an example of:
Answer: An improper payment due to patient status error
Billing an inpatient admission when documentation supports only outpatient observation status is an improper payment resulting from incorrect patient status determination.
Which of the following is considered a 'covered entity' under HIPAA?
Answer: A health plan that pays for medical services
HIPAA defines covered entities as health plans, healthcare clearinghouses, and healthcare providers that transmit health information electronically.
When a provider self-discloses a potential FCA violation through the OIG's Self-Disclosure Protocol (SDP), what is a key benefit compared to government-initiated investigation?
Answer: Potential to resolve the matter with reduced multipliers below the standard 3x damages
The SDP allows providers to potentially settle for less than treble damages—typically a 1.5x multiplier—whereas government-initiated cases can result in the full 3x damages under the FCA.
A coder is asked by a physician to add a diagnosis code not documented in the medical record to justify a procedure. The coder should:
Answer: Refuse and document the request, reporting it through compliance channels
Coders must only assign codes supported by documentation; adding undocumented codes constitutes fraud, and the request should be refused and reported through compliance channels.
The Compliance Program Guidance issued by the OIG is directed at which audience?
Answer: Various healthcare industry segments including hospitals, physicians, and suppliers
The OIG has issued Compliance Program Guidance documents for numerous healthcare industry segments, including hospitals, physician practices, third-party billing companies, and durable medical equipment suppliers.
Which scenario represents a violation of the Civil Monetary Penalties Law (CMPL)?
Answer: A provider submitting claims for services rendered by an excluded individual
Submitting claims for services provided by an individual or entity on the OIG exclusion list violates the CMPL and can result in penalties up to $10,000 per claim plus three times the amount claimed.
Under CMS's Two-Midnight Rule for inpatient hospital admissions, Medicare will generally pay the inpatient rate when the admitting physician expects the patient to require hospital care spanning at least:
Answer: Two midnights of medically necessary hospital care
The Two-Midnight Rule states that Medicare will pay the inpatient rate when the physician reasonably expects the patient to require medically necessary care crossing two midnights.