CPC Compliance and Regulatory Guidelines 3 — Questions and Answers
Question 1: Which OIG tool allows healthcare organizations to self-disclose potential fraud and abuse violations to avoid larger penalties?
- Corporate Integrity Agreement (CIA)
- Self-Disclosure Protocol (SDP) (Correct answer)
- Compliance Advisory Opinion
- Exclusion List Review
Correct 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.
Question 2: Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring Medicare patients for designated health services to entities where:
- The referring physician lacks board certification
- The physician or immediate family member has a financial relationship, unless an exception applies (Correct answer)
- The service is not covered under Medicare Part A
- The patient has not provided written consent
Correct 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.
Question 3: Which element is NOT one of the seven core components of an effective compliance program per OIG guidance?
- Written policies and procedures
- Designation of a compliance officer
- Mandatory profit-sharing with compliance staff (Correct answer)
- Open lines of communication
Correct 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.
Question 4: When a coder assigns separate CPT codes for services that should be reported with a single comprehensive code, this practice is called:
- Upcoding
- Unbundling (Correct answer)
- Balance billing
- Dual coding
Correct answer: Unbundling
Unbundling is the improper practice of billing component services separately when a single comprehensive code should be used, inflating reimbursement.
Question 5: A provider who is listed on the OIG Exclusion List is prohibited from:
- Billing any private insurance carrier
- Participating in federal healthcare programs including Medicare and Medicaid (Correct answer)
- Treating patients without written consent
- Using electronic health records systems
Correct 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.
Question 6: The National Correct Coding Initiative (NCCI) was developed by CMS primarily to:
- Define medical necessity criteria for inpatient admissions
- Prevent improper payment of procedure codes that should not be billed together (Correct answer)
- Establish ICD-10-CM coding guidelines
- Standardize physician credentialing requirements
Correct 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.
Question 7: Under the Anti-Kickback Statute, which of the following arrangements would most likely be considered a safe harbor?
- A physician receives free office space from a hospital in exchange for referrals
- A vendor offers a discount that is properly disclosed and reflected in cost reports (Correct answer)
- A laboratory pays physicians per-click fees for ordering tests
- A DME supplier gives patients gift cards for choosing their products
Correct 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.
CPC Compliance and Regulatory Guidelines 3
Which OIG tool allows healthcare organizations to self-disclose potential fraud and abuse violations to avoid larger penalties?