CRCR Healthcare Compliance and Regulations 4 — Questions and Answers
Question 1: Which exception to the Stark Law allows a hospital to pay a physician for services personally performed by that physician at fair market value?
- In-Office Ancillary Services Exception
- Personal Services Arrangements Exception (Correct answer)
- Bona Fide Employment Exception
- Isolated Transactions Exception
Correct answer: Personal Services Arrangements Exception
The Personal Services Arrangements Exception permits compensation to physicians for services they personally provide at fair market value under a written agreement.
Question 2: Billing for a service that was never performed is classified as which type of fraud?
- Upcoding
- Unbundling
- Phantom billing (Correct answer)
- Duplicate billing
Correct answer: Phantom billing
Phantom billing refers to submitting claims for services, procedures, or supplies that were never actually provided to the patient.
Question 3: Under the Anti-Kickback Statute, the safe harbor for personal services requires that the aggregate compensation be set in advance and not exceed what standard?
- Medicare fee schedule rates
- Fair market value (Correct answer)
- Medicaid cost report benchmarks
- Regional average compensation surveys
Correct answer: Fair market value
The personal services safe harbor requires that aggregate compensation is set in advance, consistent with fair market value, and not determined by volume or value of referrals.
Question 4: A hospital submits a claim using procedure codes that should be billed together under a single bundled code. This practice is called:
- Upcoding
- Unbundling (Correct answer)
- Fragmentation
- Duplicate billing
Correct answer: Unbundling
Unbundling is the practice of billing separately for services that payers require to be billed under a single bundled code, resulting in higher reimbursement.
Question 5: Which CMS program uses statistical analysis to identify aberrant billing patterns and flag providers for potential audit?
- Recovery Audit Contractor (RAC) program
- Comprehensive Error Rate Testing (CERT)
- Targeted Probe and Educate (TPE)
- Fraud Prevention System (FPS) (Correct answer)
Correct answer: Fraud Prevention System (FPS)
The Fraud Prevention System (FPS) uses predictive analytics and data mining to identify aberrant billing patterns before and after payment.
Question 6: What is the term for a voluntary self-disclosure program through which providers report potential fraud to the OIG in exchange for reduced penalties?
- Corporate Integrity Agreement
- Self-Disclosure Protocol (Correct answer)
- Whistleblower Safe Harbor
- Compliance Advisory Program
Correct answer: Self-Disclosure Protocol
The OIG's Self-Disclosure Protocol allows providers to voluntarily report potential fraud violations and typically results in reduced civil monetary penalties.
Question 7: Under EMTALA, which patients must receive a medical screening examination at a hospital emergency department?
- Only Medicare and Medicaid patients
- Only patients who have pre-authorization from their insurer
- Any individual who comes to the emergency department requesting examination (Correct answer)
- Only patients presenting with life-threatening emergencies
Correct answer: Any individual who comes to the emergency department requesting examination
EMTALA requires hospitals to provide a medical screening examination to any individual who comes to the ED requesting examination or treatment, regardless of insurance status.
CRCR Healthcare Compliance and Regulations 4
Which exception to the Stark Law allows a hospital to pay a physician for services personally performed by that physician at fair market value?