CPC Compliance & Regulatory Guidelines 3 — Questions and Answers
Question 1: A physician bills for a service that was performed by a medical student without direct supervision. Under Medicare rules, this represents:
- Appropriate incident-to billing
- Fraudulent billing (Correct answer)
- Teaching physician exception billing
- Locum tenens billing
Correct answer: Fraudulent billing
Medical students cannot independently bill Medicare; a qualified physician must perform or directly supervise services billed, making unsupervised student billing fraudulent.
Question 2: 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?
- 1 day
- 3 days (Correct answer)
- 7 days
- 14 days
Correct 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.
Question 3: Which program uses data analytics and algorithms to proactively identify potentially fraudulent Medicare claims BEFORE payment is made?
- Recovery Audit Contractor (RAC) program
- Fraud Prevention System (FPS) (Correct answer)
- Zone Program Integrity Contractor (ZPIC)
- Comprehensive Error Rate Testing (CERT)
Correct 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.
Question 4: 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?
- State Attorney General only
- HHS and prominent media outlets in the affected area (Correct answer)
- FBI Cyber Division
- CMS directly
Correct 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.
Question 5: What does it mean when a provider is placed on the OIG's List of Excluded Individuals and Entities (LEIE)?
- They must pay a civil monetary penalty
- Federal healthcare programs cannot pay for their services (Correct answer)
- Their medical license is revoked
- They must enter a Corporate Integrity Agreement
Correct 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.
Question 6: A compliance officer discovers a pattern of incorrect modifier usage that resulted in underpayments to the practice. The BEST immediate action is to:
- Ignore it since it benefits the payer
- Conduct a root cause analysis and correct the billing error (Correct answer)
- Report it to the FBI
- Retroactively recode all claims for the past 10 years
Correct 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.
Question 7: Which entity publishes the Work Plan each year identifying areas of focus for compliance audits of Medicare and Medicaid programs?
- CMS
- OIG (Office of Inspector General) (Correct answer)
- DOJ
- AMA
Correct 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.
CPC Compliance & Regulatory Guidelines 3
A physician bills for a service that was performed by a medical student without direct supervision.
Under Medicare rules, this represents: