CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations Flashcards
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Read the first 6 CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations flashcards as text
What does the False Claims Act prohibit in healthcare billing?
Answer: Knowingly submitting false or fraudulent claims for payment to the federal government
The FCA imposes civil and criminal penalties for submitting false claims to federal healthcare programs like Medicare and Medicaid.
What is the role of a Compliance Officer in a healthcare organization?
Answer: To oversee the organization's compliance program including policy development, education, monitoring, and response to violations
The Compliance Officer is responsible for developing, implementing, and overseeing the organization's compliance program to prevent and detect violations.
Which federal agency publishes the OIG Work Plan that identifies compliance priorities for healthcare organizations?
Answer: The Office of Inspector General of the Department of Health and Human Services
The OIG publishes an annual Work Plan identifying audit and enforcement priorities which healthcare organizations use to guide their compliance monitoring.
What is upcoding and why is it illegal?
Answer: Assigning a higher-level code than the documentation supports to receive greater reimbursement which constitutes fraud
Upcoding is submitting a code representing a more intensive or expensive service than was actually documented or provided, constituting healthcare fraud.
What does HIPAA's minimum necessary standard require?
Answer: That covered entities use or disclose only the minimum amount of protected health information needed to accomplish the intended purpose
The minimum necessary standard limits the amount of PHI disclosed or accessed to what is required for the specific purpose.
A hospital receives a subpoena requesting patient records. What is the appropriate response?
Answer: Contact legal counsel and follow established protocols for responding to legal requests which may include providing records under specific conditions
Legal requests for records must be handled through established legal and compliance channels not unilaterally by billing staff.