Compliance and Regulatory Guidelines Flashcards

Which OIG tool allows healthcare organizations to self-disclose potential fraud and abuse violations to avoid larger penalties?

Answer: Self-Disclosure Protocol (SDP)

The OIG's Self-Disclosure Protocol allows providers to voluntarily disclose potential violations, typically resulting in lower multipliers and penalties than if discovered through audit.

Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring Medicare patients for designated health services to entities where:

Answer: The physician or immediate family member has a financial relationship, unless an exception applies

Stark Law bars self-referrals to entities with which the physician has a direct or indirect financial relationship, with specific statutory exceptions.

Which element is NOT one of the seven core components of an effective compliance program per OIG guidance?

Answer: Mandatory profit-sharing with compliance staff

The seven OIG compliance program elements do not include profit-sharing; they focus on policies, oversight, training, auditing, communication, enforcement, and response to detected issues.

When a coder assigns separate CPT codes for services that should be reported with a single comprehensive code, this practice is called:

Answer: Unbundling

Unbundling is the improper practice of billing component services separately when a single comprehensive code should be used, inflating reimbursement.

A provider who is listed on the OIG Exclusion List is prohibited from:

Answer: Participating in federal healthcare programs including Medicare and Medicaid

Excluded individuals and entities are barred from participating in Medicare, Medicaid, and all other federal healthcare programs, and hiring them can result in significant penalties.

The National Correct Coding Initiative (NCCI) was developed by CMS primarily to:

Answer: Prevent improper payment of procedure codes that should not be billed together

NCCI edits are code pairs that CMS uses to detect and deny claims where two codes are billed together improperly, preventing unbundling and other coding abuses.

Under the Anti-Kickback Statute, which of the following arrangements would most likely be considered a safe harbor?

Answer: A vendor offers a discount that is properly disclosed and reflected in cost reports

The discount safe harbor protects price reductions from sellers to buyers when the discount is properly disclosed and reported as required by law.