CMC Regulatory Compliance & Legal Framework 4 — Questions and Answers
Question 1: Under the False Claims Act, a whistleblower (qui tam relator) who reports a cardiac hospital's fraudulent Medicare billing may receive:
- No financial benefit, only legal protection
- A percentage (15–30%) of the government's recovery (Correct answer)
- A fixed $10,000 reward
- Immunity from prosecution only
Correct answer: A percentage (15–30%) of the government's recovery
The False Claims Act's qui tam provision allows whistleblowers to receive 15–30% of government recoveries from fraud actions they initiate.
Question 2: A cardiologist wants to discuss a patient's post-MI management with a specialist via email. Under HIPAA, this is permissible if:
- Both physicians are in the same health system
- Reasonable safeguards are in place, such as encryption (Correct answer)
- The email is sent during business hours only
- The patient has signed a general release form
Correct answer: Reasonable safeguards are in place, such as encryption
HIPAA permits PHI transmission via email for treatment purposes when reasonable safeguards like encryption are implemented.
Question 3: The Physician Payments Sunshine Act (Open Payments) requires manufacturers to report payments to physicians. This primarily aims to:
- Limit pharmaceutical advertising
- Increase transparency regarding financial relationships that may influence clinical decisions (Correct answer)
- Set caps on physician compensation
- Regulate device pricing
Correct answer: Increase transparency regarding financial relationships that may influence clinical decisions
Open Payments requires public disclosure of financial relationships between manufacturers and physicians to promote transparency and reduce conflicts of interest.
Question 4: A cardiac rehabilitation program wants to bill Medicare for services provided to a patient who did not have a qualifying event. This would constitute:
- A coding error correctable by amendment
- Medicare fraud (Correct answer)
- An acceptable billing practice if clinically justified
- An EMTALA violation
Correct answer: Medicare fraud
Billing Medicare for services when coverage criteria are not met constitutes fraud, potentially triggering False Claims Act liability.
Question 5: When a cardiac patient lacks decision-making capacity and has no advance directive, the legal surrogate decision-maker is typically prioritized in which order?
- Friend, adult child, spouse
- Spouse, adult child, parent (state law hierarchy) (Correct answer)
- Attending physician, then ethicist
- Nearest family member regardless of relationship
Correct answer: Spouse, adult child, parent (state law hierarchy)
Most state laws establish a hierarchy of surrogates beginning with a spouse, then adult children, then parents, in the absence of a designated healthcare proxy.
Question 6: A hospital's compliance officer discovers that cardiac procedure documentation consistently overstates severity to increase DRG weight. The appropriate immediate action is:
- Wait until the annual audit to address it
- Halt the pattern, self-disclose to CMS, and implement corrective action (Correct answer)
- Simply retrain the coding staff
- Destroy the problematic records
Correct answer: Halt the pattern, self-disclose to CMS, and implement corrective action
Self-disclosure to CMS and prompt corrective action reduce False Claims Act liability and demonstrate good-faith compliance efforts.
Question 7: Which federal law prohibits discrimination based on disability in hospitals receiving federal funding, directly affecting cardiac care accessibility?
- HIPAA
- Section 504 of the Rehabilitation Act and the ADA (Correct answer)
- EMTALA
- The Affordable Care Act Section 1557 only
Correct answer: Section 504 of the Rehabilitation Act and the ADA
Section 504 of the Rehabilitation Act and Title III of the ADA prohibit disability discrimination in healthcare facilities receiving federal funding.
CMC Regulatory Compliance & Legal Framework 4
Under the False Claims Act, a whistleblower (qui tam relator) who reports a cardiac hospital's fraudulent Medicare billing may receive: