Medical Billing Software Regulatory Frameworks & Compliance 3 — Questions and Answers
Question 1: The Anti-Kickback Statute (AKS) prohibits which of the following arrangements in medical billing?
- Charging Medicare patients a copayment waiver as standard policy (Correct answer)
- Billing for services rendered by credentialed staff
- Submitting claims within the timely filing deadline
- Documenting medical necessity in the clinical note
Correct answer: Charging Medicare patients a copayment waiver as standard policy
Routinely waiving Medicare copayments without individualized financial hardship assessment violates the AKS because it can induce patients to use services covered by federal programs.
Question 2: A claim submitted to Medicare for a service that was never rendered constitutes a violation of the:
- Stark Law
- False Claims Act (FCA) (Correct answer)
- Emergency Medical Treatment and Labor Act (EMTALA)
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
Correct answer: False Claims Act (FCA)
The False Claims Act imposes civil liability on any person who knowingly submits a false or fraudulent claim for payment to the federal government.
Question 3: Which CMS program uses statistical sampling and extrapolation to recover overpayments across a provider's entire claim population?
- Targeted Probe and Educate (TPE)
- Recovery Audit Contractor (RAC) (Correct answer)
- Comprehensive Error Rate Testing (CERT)
- Medicare Administrative Contractor (MAC)
Correct answer: Recovery Audit Contractor (RAC)
RAC auditors use statistical sampling and extrapolation, meaning a finding in a sample can be applied to all similar claims in the review period.
Question 4: Under Medicare's Timely Filing Rule, the standard deadline for submitting an initial claim is:
- 90 days from date of service
- 180 days from date of service
- One calendar year (12 months) from date of service (Correct answer)
- Two years from date of service
Correct answer: One calendar year (12 months) from date of service
Medicare requires initial claims to be filed within one year (365 days) of the date of service, or the claim will be denied.
Question 5: ICD-10-CM coding guidelines require that a 'probable' or 'suspected' diagnosis:
- Be coded as confirmed in the inpatient setting only (Correct answer)
- Never be coded under any circumstance
- Be coded only when documentation includes lab confirmation
- Be coded as confirmed for all outpatient visits
Correct answer: Be coded as confirmed in the inpatient setting only
In the inpatient setting, conditions documented as probable, suspected, or likely may be coded as established; this rule does not apply to outpatient coding.
Question 6: HIPAA's Transaction and Code Set standards require that electronic claims be submitted in which format?
- 837P or 837I (ANSI X12) (Correct answer)
- CMS-1450 (UB-04) paper format
- HL7 FHIR R4 messaging
- CSV flat-file format
Correct answer: 837P or 837I (ANSI X12)
HIPAA mandates the use of ANSI X12 837P (professional) or 837I (institutional) transaction sets for electronic health care claim submissions.
Question 7: A provider who self-discloses a potential FCA violation to the OIG through the Self-Disclosure Protocol typically benefits from:
- Full immunity from all civil and criminal penalties
- Reduced multiplier on damages (as low as 1.5x vs. the standard 3x) (Correct answer)
- Automatic exclusion from Medicare for 5 years
- Transfer of liability to the billing software vendor
Correct answer: Reduced multiplier on damages (as low as 1.5x vs. the standard 3x)
OIG's Self-Disclosure Protocol can reduce the damages multiplier to as low as 1.5 times the overpayment amount, compared to the FCA's standard treble damages.
Medical Billing Software Regulatory Frameworks & Compliance 3
The Anti-Kickback Statute (AKS) prohibits which of the following arrangements in medical billing?