CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 2 — Questions and Answers
Question 1: What does the False Claims Act prohibit in healthcare billing?
- Submitting claims without a patient signature
- Knowingly submitting false or fraudulent claims for payment to the federal government (Correct answer)
- Billing Medicare for services provided by a non-credentialed provider
- Charging patients more than the Medicare allowable rate
Correct 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.
The False Claims Act prohibits knowingly submitting false, fictitious, or fraudulent claims to the federal government for payment including Medicare and Medicaid. Violations can result in civil penalties plus treble damages. The FCA also includes a qui tam provision that allows private individuals to file suit on behalf of the government and share in any recovery.
Question 2: What is the role of a Compliance Officer in a healthcare organization?
- To process Medicare billing submissions
- To oversee the organization's compliance program including policy development, education, monitoring, and response to violations (Correct answer)
- To manage patient financial assistance applications
- To conduct clinical audits of physician documentation
Correct 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.
A Compliance Officer leads the healthcare organization's compliance program including developing and updating policies, delivering compliance education to staff, monitoring billing and clinical practices, investigating potential violations, and reporting to the board or governing body. An effective compliance program incorporates the seven elements recommended by the OIG.
Question 3: Which federal agency publishes the OIG Work Plan that identifies compliance priorities for healthcare organizations?
- CMS
- The Office of Inspector General of the Department of Health and Human Services (Correct answer)
- The Joint Commission
- The American Hospital Association
Correct 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.
The Office of Inspector General of the Department of Health and Human Services publishes an annual Work Plan that identifies the OIG's planned audits, evaluations, and investigations of Medicare and Medicaid programs. Healthcare organizations use the Work Plan to proactively assess their own billing and coding practices in areas the OIG has flagged.
Question 4: What is upcoding and why is it illegal?
- Assigning a higher-level code than the documentation supports to receive greater reimbursement which constitutes fraud (Correct answer)
- Using the wrong version of ICD codes
- Billing for services on a date earlier than they were provided
- Submitting a claim without a valid NPI
Correct 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.
Upcoding is the practice of billing a procedure code that represents a higher level of complexity than the service actually documented or rendered. It is illegal because it results in fraudulent overpayment from federal or commercial payers and can result in False Claims Act liability, exclusion from Medicare and Medicaid, and criminal prosecution.
Question 5: What does HIPAA's minimum necessary standard require?
- That only the minimum number of staff be involved in patient care
- That covered entities use or disclose only the minimum amount of protected health information needed to accomplish the intended purpose (Correct answer)
- That the smallest possible copayment be charged to patients
- That all PHI disclosures must have written authorization
Correct 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.
HIPAA's minimum necessary standard requires that covered entities and business associates access, use, or disclose only the amount of protected health information reasonably necessary to accomplish the specific purpose. For example a billing department should only access the diagnoses and demographic information needed to process a claim, not an entire medical record.
Question 6: A hospital receives a subpoena requesting patient records. What is the appropriate response?
- Refuse to provide any records to maintain patient confidentiality
- Contact legal counsel and follow established protocols for responding to legal requests which may include providing records under specific conditions (Correct answer)
- Immediately fax all patient records to the requesting party
- Notify the patient and wait for their verbal approval before responding
Correct 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.
When a subpoena or other legal process is received the appropriate response is to immediately involve the organization's legal counsel and follow the organization's established policies for responding to legal requests. Unauthorized disclosure or refusal to comply can both create liability.
CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 2
What does the False Claims Act prohibit in healthcare billing?