Medical Billing Software Regulatory Frameworks & Compliance 4 — Questions and Answers
Question 1: Under the Stark Law (Physician Self-Referral Law), a physician may NOT refer Medicare patients for designated health services to an entity in which the physician has a financial relationship UNLESS:
- The physician obtains patient consent
- A recognized Stark exception applies (Correct answer)
- The service is billed under a global fee
- The entity holds a valid CLIA certificate
Correct answer: A recognized Stark exception applies
Stark Law prohibitions are absolute unless the arrangement falls within a statutory or regulatory exception, such as the in-office ancillary services exception.
Question 2: Which organization accredits ambulatory surgery centers and hospitals, and whose deemed status allows providers to participate in Medicare without a separate state survey?
- CMS
- OIG
- The Joint Commission (TJC) (Correct answer)
- URAC
Correct answer: The Joint Commission (TJC)
The Joint Commission holds CMS-granted deemed status, meaning its accreditation satisfies Medicare Conditions of Participation requirements.
Question 3: When a commercial payer requests a medical record audit and the provider fails to respond within the contractual timeframe, the typical consequence is:
- The claim is automatically approved
- The payer may recoup the paid amount or deny future claims (Correct answer)
- CMS issues a corrective action plan
- The provider's NPI is deactivated
Correct answer: The payer may recoup the paid amount or deny future claims
Most payer contracts allow recoupment or prospective denial if providers fail to furnish requested records within the specified audit response window.
Question 4: The Affordable Care Act (ACA) Section 6402 requires providers to report and return identified Medicare/Medicaid overpayments within:
- 30 days of identification
- 60 days of identification (Correct answer)
- 90 days of identification
- One year of identification
Correct answer: 60 days of identification
ACA Section 6402 mandates that overpayments be reported and returned within 60 days of identification, or they become false claims under the FCA.
Question 5: A compliance program that meets OIG guidance must include which of the following elements?
- Daily claim volume tracking and payer scorecards
- Written policies, employee training, and an internal audit process (Correct answer)
- Annual renegotiation of all payer contracts
- Quarterly CMS cost report submissions
Correct answer: Written policies, employee training, and an internal audit process
OIG's seven compliance program elements include written standards, training, open lines of communication, auditing, and corrective action procedures.
Question 6: Which modifier signals to Medicare that a service was provided at a reduced level due to extenuating circumstances or because only part of the service was performed?
- Modifier 59
- Modifier 52 (Correct answer)
- Modifier 25
- Modifier 57
Correct answer: Modifier 52
Modifier 52 indicates that a service or procedure was partially reduced or eliminated at the physician's discretion, prompting proportional reimbursement.
Question 7: Under CMS's 2-midnight rule, inpatient admission is appropriate when the treating physician expects the patient to require hospital care spanning:
- At least 4 hours
- At least 8 hours
- At least 2 midnights (Correct answer)
- At least 3 midnights
Correct answer: At least 2 midnights
The 2-midnight rule states that inpatient admission is generally appropriate when a physician reasonably expects the patient to need hospital care crossing two midnights.
Medical Billing Software Regulatory Frameworks & Compliance 4
Under the Stark Law (Physician Self-Referral Law), a physician may NOT refer Medicare patients for designated health services to an entity in which the physician has a financial relationship UNLESS: