Medical Billing Software Regulatory Frameworks & Compliance 5 — Questions and Answers
Question 1: The HITECH Act expanded HIPAA enforcement by increasing the maximum civil monetary penalty tier to:
- $10,000 per violation category per year
- $250,000 per violation category per year
- $1.5 million per violation category per year (Correct answer)
- $5 million per violation category per year
Correct answer: $1.5 million per violation category per year
HITECH raised the maximum HIPAA civil monetary penalty to $1.5 million per violation category per calendar year.
Question 2: A medical billing software system that automatically scrubs claims for National Correct Coding Initiative (NCCI) edits is helping providers avoid:
- Duplicate billing of the same service on the same date
- Unbundling or mutually exclusive procedure code combinations (Correct answer)
- Timely filing denials from secondary payers
- Upcoding of evaluation and management services
Correct answer: Unbundling or mutually exclusive procedure code combinations
NCCI edits identify procedure code pairs that should not be billed together because one is bundled into the other or they are mutually exclusive.
Question 3: Which entity has authority to exclude providers from participation in all federal health care programs, not just Medicare?
- CMS Office of Financial Management
- Office of Inspector General (OIG) (Correct answer)
- Office for Civil Rights (OCR)
- Centers for Disease Control (CDC)
Correct answer: Office of Inspector General (OIG)
The OIG has authority under Section 1128 of the Social Security Act to exclude individuals and entities from all federal health care programs.
Question 4: Under Medicare's incident-to billing rules, services billed under the supervising physician's NPI must be performed:
- In a hospital outpatient department
- In the physician's office with the physician present in the suite (Correct answer)
- Via telehealth only during a public health emergency
- Within 90 days of the initial physician visit
Correct answer: In the physician's office with the physician present in the suite
Incident-to billing requires the supervising physician to be physically present in the office suite (not necessarily the same room) when the NPP performs the service.
Question 5: The COB (Coordination of Benefits) process in medical billing software ensures that:
- Patients with dual coverage are never billed more than their actual out-of-pocket cost (Correct answer)
- Primary and secondary payers receive claims in the wrong order to maximize reimbursement
- Electronic remittance advice is converted to paper EOBs
- Provider credentialing is current with all payers
Correct answer: Patients with dual coverage are never billed more than their actual out-of-pocket cost
COB rules ensure combined payments from primary and secondary payers do not exceed the actual charges, protecting patients from overpayment.
Question 6: A provider who knowingly uses a billing code that results in higher payment than the service actually rendered is committing:
- Downcoding
- Upcoding (Correct answer)
- Unbundling
- Balance billing
Correct answer: Upcoding
Upcoding is the fraudulent practice of billing for a higher-level or more expensive service than was actually provided.
Question 7: State Medicaid programs may have timely filing deadlines that differ from Medicare's 12-month rule. When a provider is uncertain about a state's deadline, the correct resource is:
- The CMS Medicare Claims Processing Manual
- The applicable state Medicaid provider manual or billing guidelines (Correct answer)
- The OIG Compliance Program Guidance for Hospitals
- The AMA CPT codebook appendix
Correct answer: The applicable state Medicaid provider manual or billing guidelines
Each state's Medicaid agency publishes its own provider manual, which specifies claim submission deadlines that may be shorter or longer than Medicare's standard.
Medical Billing Software Regulatory Frameworks & Compliance 5
The HITECH Act expanded HIPAA enforcement by increasing the maximum civil monetary penalty tier to: