CMC Compliance & Regulatory Knowledge 2

Question 1

Under HIPAA, which action by a covered entity constitutes a breach requiring patient notification?

Accepted Answer

An employee viewing a celebrity patient's records out of curiosity

Answer

Unauthorized access to PHI for non-treatment, non-payment, and non-operations purposes—such as curiosity—constitutes a HIPAA breach requiring notification.

Question 2

The False Claims Act allows private individuals to file lawsuits on behalf of the government through which mechanism?

Accepted Answer

Qui tam provisions

Answer

The False Claims Act's qui tam provisions allow whistleblowers (relators) to sue on the government's behalf and receive a portion of any recovery.

Question 3

A medical coder discovers a pattern of upcoding in claims submitted over the past year. What is the FIRST recommended step under a compliance program?

Accepted Answer

Report findings to the compliance officer or hotline

Answer

Compliance programs require employees to report suspected violations internally to the compliance officer or designated hotline as the first step.

Question 4

Which federal regulation governs the Medicare Advantage (Part C) program's coding and risk adjustment requirements?

Accepted Answer

42 CFR Part 422

Answer

42 CFR Part 422 governs Medicare Advantage organizations, including risk adjustment data validation (RADV) audits and coding accuracy requirements.

Question 5

What is the primary purpose of the OIG's List of Excluded Individuals/Entities (LEIE)?

Accepted Answer

To prevent Medicare and Medicaid payment to sanctioned individuals or entities

Answer

The LEIE identifies individuals and entities excluded from participation in federal healthcare programs; billing for services by excluded parties results in significant penalties.

(CMC) Certified Medical Coder Practice Test

(CMC) Certified Medical Coder Practice Test

CMC Compliance & Regulatory Knowledge 2