Compliance and Regulatory Guidelines Flashcards
7 cards from real CPC 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 and Regulatory Guidelines flashcards as text
Which federal law established the False Claims Act, allowing the government to sue individuals or companies that defraud federal programs?
Answer: False Claims Act of 1863
The False Claims Act of 1863 (updated in 1986) allows the government—and whistleblowers—to sue parties that knowingly submit false claims to federal programs like Medicare.
Under HIPAA, which type of information is classified as Protected Health Information (PHI)?
Answer: A patient's name combined with their diagnosis
PHI is individually identifiable health information that includes any data element that can link a person to their health condition, such as a name paired with a diagnosis.
A coder bills a complex office visit when documentation only supports a straightforward visit to increase reimbursement. This is an example of:
Answer: Upcoding
Upcoding is reporting a higher-level service than what is documented or medically justified, which constitutes fraud.
Which CMS program requires providers to report quality measures and can affect Medicare reimbursement rates?
Answer: Merit-based Incentive Payment System (MIPS)
MIPS is part of the Quality Payment Program under MACRA and ties Medicare reimbursement adjustments to quality, cost, improvement activities, and promoting interoperability.
What is the primary purpose of an Advance Beneficiary Notice (ABN)?
Answer: To inform Medicare patients of services that may not be covered so they can decide whether to receive them
An ABN notifies Medicare beneficiaries before a service is rendered that Medicare may not pay, allowing them to make an informed financial decision.
Which of the following best describes the 'qui tam' provision of the False Claims Act?
Answer: It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds
Qui tam provisions enable private individuals (relators) to bring lawsuits on behalf of the government and receive a portion of any recovered damages.
A hospital's compliance program discovers a billing error that resulted in overpayment from Medicare. Under the 60-day rule, what must the provider do?
Answer: Report and return the overpayment within 60 days of identification
The Affordable Care Act's 60-day rule requires providers to report and return Medicare/Medicaid overpayments within 60 days of identification or face False Claims Act liability.