CTP Legal, Ethical & Regulatory Compliance 4 — Questions and Answers
Question 1: A telehealth provider bills Medicare for a synchronous audio-video visit but the patient only had audio. What is the compliance concern?
- Upcoding — billing for a higher-complexity service than delivered
- Undercoding — billing for less than the service provided
- Duplicate billing error
- Modifier 95 misuse — video was not used as required for the billed code (Correct answer)
Correct answer: Modifier 95 misuse — video was not used as required for the billed code
Modifier 95 signifies a synchronous telemedicine service using interactive audio-video technology; using it when only audio was provided constitutes fraudulent billing.
Question 2: Which law specifically prohibits healthcare providers from offering remuneration to induce patient referrals for federally reimbursed services?
- False Claims Act
- Anti-Kickback Statute (AKS) (Correct answer)
- Stark Law (Physician Self-Referral Law)
- EMTALA
Correct answer: Anti-Kickback Statute (AKS)
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce referrals for services covered by federal healthcare programs.
Question 3: Under the Stark Law, a telehealth organization where a physician holds a financial interest refers patients to that organization's services. This is:
- Permissible because telehealth is exempt
- A potential violation unless a Stark Law exception applies (Correct answer)
- Governed solely by the Anti-Kickback Statute, not Stark
- Allowed if the physician discloses the interest to the patient
Correct answer: A potential violation unless a Stark Law exception applies
The Stark Law prohibits physician self-referrals to entities with which the physician has a financial relationship unless a specific regulatory exception applies.
Question 4: A telehealth patient discloses suicidal ideation. The provider is in a different state than the patient. Which state's duty-to-warn laws apply?
- The state where the provider holds their license
- The state where the provider's practice is registered
- The state where the patient is physically located (Correct answer)
- Federal law overrides all state duty-to-warn statutes
Correct answer: The state where the patient is physically located
Duty-to-warn obligations are governed by the laws of the state where the patient is physically located at the time of the session.
Question 5: What does EMTALA require of hospitals that offer telehealth emergency consultations to other facilities?
- Hospitals must provide consultations free of charge
- Consulting hospitals must accept appropriate transfers if they have the capacity (Correct answer)
- Telehealth consultations exempt facilities from EMTALA requirements
- Only the referring facility bears EMTALA obligations
Correct answer: Consulting hospitals must accept appropriate transfers if they have the capacity
Under EMTALA, a hospital with specialized capabilities must accept transfers of patients with emergency medical conditions from referring facilities if it has the capacity.
Question 6: A telehealth provider in a group practice wants to share a patient's mental health records with a colleague for consultation. Which additional protection may apply beyond HIPAA?
- FERPA protections
- 42 CFR Part 2 if the records involve substance use disorder treatment (Correct answer)
- CAN-SPAM regulations
- FTC Health Breach Notification Rule
Correct answer: 42 CFR Part 2 if the records involve substance use disorder treatment
42 CFR Part 2 imposes stricter confidentiality requirements on substance use disorder treatment records, requiring patient consent for disclosures even within a treating team.
Question 7: Which element is REQUIRED for a telehealth informed consent process to be legally valid?
- Consent must be obtained by a physician specifically, not a nurse or MA
- The patient must demonstrate understanding and voluntarily agree without coercion (Correct answer)
- Consent must be notarized for telehealth sessions
- Written consent is mandatory; verbal consent is never sufficient
Correct answer: The patient must demonstrate understanding and voluntarily agree without coercion
Valid informed consent requires that the patient understands the information provided, has decision-making capacity, and agrees voluntarily and without coercion.
CTP Legal, Ethical & Regulatory Compliance 4
A telehealth provider bills Medicare for a synchronous audio-video visit but the patient only had audio.
What is the compliance concern?