Compliance and Regulatory Guidelines Flashcards

Which HIPAA rule specifically addresses the security of electronic Protected Health Information (ePHI)?

Answer: HIPAA Security Rule

The HIPAA Security Rule requires covered entities and business associates to implement administrative, physical, and technical safeguards to protect ePHI.

A Medicare patient is admitted to the hospital. The hospital bills for services provided by an employed physician without separately identifying those services. What billing model does this represent?

Answer: Provider-based billing

Provider-based billing occurs when a hospital-owned clinic bills both a facility fee and a professional fee, with the physician's services billed under the hospital's provider number.

What does the term 'medical necessity' mean in the context of healthcare billing compliance?

Answer: Services that are reasonable and necessary for diagnosing or treating an illness or injury based on accepted standards of care

Medical necessity requires that services be appropriate, consistent with diagnosis, not provided primarily for convenience, and meeting accepted standards of medical practice.

Which federal agency oversees the Medicare and Medicaid programs and enforces compliance with their billing requirements?

Answer: Centers for Medicare & Medicaid Services (CMS)

CMS administers Medicare and Medicaid and sets the rules, policies, and reimbursement rates for these programs.

A physician documents and bills for a service that was actually performed by a medical assistant without physician supervision. This is an example of:

Answer: Phantom billing

Phantom billing (also called billing for services not rendered) involves charging for services that were either not performed or not performed by the billed provider.

Corporate Integrity Agreements (CIAs) are typically entered into between the OIG and a provider as a result of:

Answer: Settlement of a federal healthcare fraud investigation

CIAs are imposed as part of civil settlement agreements requiring providers to implement specific compliance measures as a condition of continued Medicare/Medicaid participation.

The 'incident-to' billing rule allows a non-physician provider's services to be billed under the supervising physician's NPI. What is a key requirement for this arrangement?

Answer: The physician must be present in the office suite and immediately available

Incident-to billing requires the supervising physician to be present in the office suite (not just the building) and immediately available to assist if needed.