Compliance and Regulatory Guidelines Flashcards

What is the maximum civil monetary penalty per false claim under the False Claims Act (as adjusted for inflation)?

Answer: $13,000 to $26,000 per claim (approximately)

FCA civil penalties are adjusted for inflation periodically; as of recent updates, they range approximately $13,000–$26,000 per false claim, plus treble (triple) damages.

Which document outlines a payer's specific coverage criteria for a medical service and is used to determine if a claim meets medical necessity requirements?

Answer: Local Coverage Determination (LCD)

LCDs are issued by Medicare Administrative Contractors (MACs) and define when and under what clinical circumstances a specific service is considered medically necessary in their jurisdiction.

Under HIPAA, a 'business associate' is best defined as:

Answer: A person or entity that performs functions on behalf of a covered entity involving the use or disclosure of PHI

A business associate is an external entity (not a workforce member) that creates, receives, maintains, or transmits PHI while performing services for a covered entity.

A coding manager notices that a specific physician consistently documents level 4 visits for all patients regardless of complexity. What is the most appropriate initial compliance action?

Answer: Conduct an internal audit and provide education to the physician

The first step in compliance is internal review (audit) followed by education; punitive or external actions should follow only if internal measures fail or fraud is confirmed.

Which statute makes it illegal to offer, pay, solicit, or receive anything of value to induce or reward referrals of items or services covered by federal healthcare programs?

Answer: Anti-Kickback Statute (AKS)

The Anti-Kickback Statute (42 U.S.C. §1320a-7b(b)) broadly prohibits remuneration intended to induce or reward referrals for services reimbursed by federal healthcare programs.

What is 'balance billing' and why is it a compliance concern in certain situations?

Answer: Charging patients more than the Medicare-approved amount when the provider is a participating provider

Participating Medicare providers (PAR providers) who accept assignment cannot bill patients more than the Medicare-approved amount; doing so violates their provider agreement.

A compliance audit reveals that a coder is routinely assigning ICD-10-CM codes not supported by physician documentation to ensure a claim will be paid. This practice is known as:

Answer: Diagnosis padding or code fabrication

Assigning diagnosis codes without supporting documentation to trigger payment constitutes fraud, often called diagnosis padding or code fabrication.