Compliance & Regulatory Guidelines Flashcards

A physician bills for a service that was performed by a medical student without direct supervision. Under Medicare rules, this represents:

Answer: Fraudulent billing

Medical students cannot independently bill Medicare; a qualified physician must perform or directly supervise services billed, making unsupervised student billing fraudulent.

The 'three-day payment window' rule requires that outpatient services provided within how many days before an inpatient admission must be bundled into the inpatient DRG payment?

Answer: 3 days

CMS's three-day payment window rule requires that most outpatient diagnostic services and related non-diagnostic services provided within 3 days prior to inpatient admission be included in the DRG payment.

Which program uses data analytics and algorithms to proactively identify potentially fraudulent Medicare claims BEFORE payment is made?

Answer: Fraud Prevention System (FPS)

The Fraud Prevention System (FPS) uses predictive analytics to flag suspicious claims for review before Medicare payment is issued, unlike RACs which review claims post-payment.

Under HIPAA, a 'covered entity' that experiences a breach affecting 500 or more individuals in a state must notify which entity within 60 days of discovery?

Answer: HHS and prominent media outlets in the affected area

For breaches affecting 500 or more residents of a state, HIPAA requires notification to HHS and to prominent media outlets serving the affected area, in addition to affected individuals.

What does it mean when a provider is placed on the OIG's List of Excluded Individuals and Entities (LEIE)?

Answer: Federal healthcare programs cannot pay for their services

Exclusion from federal healthcare programs means no payment can be made by Medicare, Medicaid, or other federal programs for any items or services furnished by the excluded individual or entity.

A compliance officer discovers a pattern of incorrect modifier usage that resulted in underpayments to the practice. The BEST immediate action is to:

Answer: Conduct a root cause analysis and correct the billing error

Both overpayments and underpayments represent inaccurate billing; identifying the root cause and correcting the error is the appropriate compliance response.

Which entity publishes the Work Plan each year identifying areas of focus for compliance audits of Medicare and Medicaid programs?

Answer: OIG (Office of Inspector General)

The OIG publishes an annual Work Plan that outlines its planned audits, evaluations, and investigations for Medicare, Medicaid, and other HHS programs.

A hospital submits claims for services that were never provided to collect Medicare reimbursement. Under the False Claims Act, the government may recover up to how many times the actual damages, plus penalties?

Answer: Three times (treble damages)

The False Claims Act provides for treble (triple) damages plus civil monetary penalties per false claim, making it the government's most powerful tool against healthcare fraud.

In medical coding compliance, 'query fatigue' refers to the risk that:

Answer: Physicians begin agreeing to queries without carefully reviewing them to avoid repeated requests

Query fatigue occurs when physicians, overwhelmed by frequent queries, begin rubber-stamping responses without proper review, potentially leading to inaccurate documentation.

Which type of Medicare audit focuses on reviewing claims from providers with aberrant billing patterns identified through data analysis, using both prepayment and post-payment review?

Answer: ZPIC/UPICreview

Zone Program Integrity Contractors (ZPICs), now called Unified Program Integrity Contractors (UPICs), conduct investigations targeting suspected fraud through both pre- and post-payment review based on data analysis.

Under Medicare's teaching physician rules, what is required for a resident to bill an E/M service at the level documented by the resident?

Answer: Teaching physician must be present during key portions and document their presence

Teaching physicians must be present during the key or critical portions of the service and must document their presence and participation for billing at the level documented.

A coder separates a bundled procedure into its component parts and bills each separately to increase reimbursement. This is called:

Answer: Unbundling

Unbundling involves billing separately for procedure components that should be included in a single, comprehensive code, violating NCCI edits and constituting fraudulent billing.

The minimum standard for a compliant healthcare compliance program, as outlined by the OIG, includes how many core elements?

Answer: 7 elements

The OIG's Compliance Program Guidance identifies 7 core elements of an effective compliance program, including written policies, a compliance officer, training, auditing, and disciplinary standards.

A Local Coverage Determination (LCD) differs from a National Coverage Determination (NCD) in that an LCD:

Answer: Is developed by a Medicare Administrative Contractor for its jurisdiction

LCDs are coverage policies developed by Medicare Administrative Contractors (MACs) that apply only within their specific geographic jurisdiction, unlike NCDs which apply nationally.

Which section of the Social Security Act governs civil monetary penalties for healthcare fraud, including submitting false claims to Medicare?

Answer: Section 1128A

Section 1128A of the Social Security Act authorizes the OIG to impose civil monetary penalties on individuals or entities that submit false or fraudulent claims to federal healthcare programs.

A Qui Tam lawsuit under the False Claims Act allows which party to file a lawsuit on behalf of the federal government?

Answer: Private whistleblower (relator)

Qui Tam provisions allow private individuals (relators or whistleblowers) to file FCA suits on the government's behalf and receive a portion of any recovery.

Under HIPAA's minimum necessary standard, when disclosing PHI for treatment purposes between treating providers, the standard:

Answer: Does not apply — treating providers may share complete records

HIPAA explicitly exempts disclosures for treatment purposes between treating providers from the minimum necessary standard, allowing complete clinical information sharing to support patient care.

A coder assigns diagnosis codes based on clinical indicators in the record without a physician's diagnosis. This practice is:

Answer: Generally prohibited — coders must code what physicians document

Coders must code diagnoses as documented by the treating physician; coding from clinical indicators without a physician diagnosis (except in specific UHDDS exceptions for inpatient coding) is improper.

What is the statute of limitations for the government to bring a civil action under the False Claims Act?

Answer: 6 years from the date of the violation, or 3 years from when the government knew/should have known (up to 10 years)

The FCA has a dual limitations period: 6 years from the violation date, or 3 years from when the government knew or reasonably should have known, whichever is later, but no more than 10 years.

Which Medicare audit program is specifically designed to measure the overall accuracy of Medicare fee-for-service payments on a national level by reviewing a statistically valid random sample of claims?

Answer: CERT

The Comprehensive Error Rate Testing (CERT) program measures the improper payment rate for Medicare FFS by reviewing a statistically valid random sample of claims paid during a given period.