CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 5 — Questions and Answers
Question 1: Under the Emergency Medical Treatment and Labor Act (EMTALA), a hospital with an emergency department must:
- Provide a medical screening exam to all individuals who come to the ED regardless of ability to pay (Correct answer)
- Treat only patients with insurance or documented ability to pay
- Transfer patients immediately if they cannot pay
- Only stabilize patients who are US citizens or legal residents
Correct answer: Provide a medical screening exam to all individuals who come to the ED regardless of ability to pay
EMTALA requires hospitals with EDs to provide a medical screening examination to anyone who presents, regardless of their ability to pay, citizenship, or insurance status.
Question 2: In healthcare compliance, 'bundling' refers to which billing scenario?
- Submitting multiple claims for the same procedure on the same date
- Combining multiple services into one single payment code as required by payer rules (Correct answer)
- Splitting a global procedure into component parts to increase reimbursement
- Billing both the facility and the professional component separately when payer rules require a single combined payment
Correct answer: Combining multiple services into one single payment code as required by payer rules
Bundling is the correct and required practice of submitting multiple services under a single code per payer rules; 'unbundling' (splitting bundled codes) is the fraudulent practice.
Question 3: Which of the following actions would constitute a HIPAA Security Rule violation?
- Encrypting a laptop containing ePHI before an employee takes it off-site
- Conducting a regular risk analysis of systems containing electronic PHI
- Allowing workforce members to share login credentials to access ePHI systems (Correct answer)
- Implementing automatic logoff for workstations that access ePHI
Correct answer: Allowing workforce members to share login credentials to access ePHI systems
Sharing login credentials undermines access controls and audit controls required by the HIPAA Security Rule, making it impossible to track individual access to ePHI.
Question 4: What does the term 'coordination of benefits' (COB) mean in revenue cycle compliance?
- Negotiating discounts with multiple payers simultaneously
- The process of determining which payer is primary and which is secondary when a patient has multiple insurance coverages (Correct answer)
- Combining patient benefits from employer plans with government programs illegally
- A billing process for dually eligible Medicare-Medicaid patients only
Correct answer: The process of determining which payer is primary and which is secondary when a patient has multiple insurance coverages
COB is the standardized process for determining the order in which multiple insurers pay claims to prevent total payment from exceeding 100% of the actual charges.
Question 5: A compliance officer discovers that a coder has been billing 99215 (highest-complexity E&M) for all established patient office visits. Which compliance risk does this BEST represent?
- Unbundling
- Upcoding (Correct answer)
- Duplicate billing
- Identity theft
Correct answer: Upcoding
Systematically billing the highest-level E&M code regardless of documentation is upcoding — inflating codes beyond what the medical record supports.
Question 6: Under the Affordable Care Act, which provision most directly affects revenue cycle compliance by requiring healthcare organizations to return Medicare and Medicaid overpayments?
- Individual mandate
- 60-day repayment rule (Section 6402) (Correct answer)
- Medicaid expansion provision
- Accountable Care Organization framework
Correct answer: 60-day repayment rule (Section 6402)
ACA Section 6402 established the 60-day rule, requiring providers to report and return identified overpayments within 60 days or face FCA liability for retaining them.
Question 7: When a healthcare organization excludes an individual or entity from participation in federal healthcare programs, which database should revenue cycle staff check before engaging any new vendor or employee?
- National Practitioner Data Bank (NPDB)
- OIG List of Excluded Individuals and Entities (LEIE) (Correct answer)
- CMS Provider Enrollment Chain and Ownership System (PECOS)
- State licensure board databases only
Correct answer: OIG List of Excluded Individuals and Entities (LEIE)
The OIG LEIE must be checked before hiring or contracting, as billing for services by an excluded person or entity — even unknowingly — can result in significant civil monetary penalties.
CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 5
Under the Emergency Medical Treatment and Labor Act (EMTALA), a hospital with an emergency department must: