Compliance & Regulatory Guidelines Flashcards

Which federal law established the Anti-Kickback Statute (AKS) that prohibits offering or receiving remuneration to induce referrals for Medicare/Medicaid services?

Answer: Social Security Act

The Anti-Kickback Statute is codified under the Social Security Act (42 U.S.C. § 1320a-7b) and prohibits remuneration intended to induce federal healthcare program referrals.

A coder assigns a higher-level E/M code than documentation supports to increase reimbursement. This practice is best described as:

Answer: Upcoding

Upcoding means billing a higher-level or more expensive service than was actually documented or provided, which constitutes fraud.

Under the Stark Law (Physician Self-Referral Law), which of the following is a designated health service (DHS) subject to its restrictions?

Answer: Clinical laboratory services

Clinical laboratory services are explicitly listed as a designated health service under the Stark Law, prohibiting self-referrals absent an applicable exception.

A Recovery Audit Contractor (RAC) identifies overpayments by reviewing Medicare claims. What is the RAC's payment model?

Answer: Contingency fee based on overpayments identified

RACs are paid on a contingency basis, receiving a percentage of the overpayments (and underpayments) they identify and recover.

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

Answer: Self-Disclosure Protocol (SDP)

The OIG's Self-Disclosure Protocol (SDP) allows providers to voluntarily report potential fraud, often resulting in reduced multipliers and penalties compared to government-initiated investigations.

What is the purpose of a National Coverage Determination (NCD) issued by CMS?

Answer: Determine whether Medicare covers a specific service nationally

An NCD is a CMS policy decision determining whether Medicare will cover a particular item or service across the entire country.

Which compliance document outlines the specific obligations a healthcare provider must meet as part of a settlement with the OIG following a fraud investigation?

Answer: Corporate Integrity Agreement

A Corporate Integrity Agreement (CIA) is a legal contract between the OIG and a provider settling a fraud case, specifying mandatory compliance obligations for a set period.