Medical Billing Software Risk Assessment & Management 4 ā Questions and Answers
Question 1: A medical practice's billing software vendor is acquired by a competitor. What risk management step should the practice take immediately?
- Review the existing BAA and contract for change-of-control clauses and data portability rights (Correct answer)
- Immediately terminate the software contract without review
- Migrate all data to paper records as a precaution
- Assume the new vendor will honor all previous agreements automatically
Correct answer: Review the existing BAA and contract for change-of-control clauses and data portability rights
Change-of-control clauses determine whether the BAA and service terms survive an acquisition and whether the practice can exit the contract.
Question 2: Which of the following is a key indicator of potential upcoding risk in a billing software audit report?
- A provider's E&M code distribution that is heavily skewed toward level 4 and 5 codes compared to peers (Correct answer)
- A provider who submits claims on Mondays more than other days
- A low claim rejection rate from the clearinghouse
- A high number of new patient registrations per month
Correct answer: A provider's E&M code distribution that is heavily skewed toward level 4 and 5 codes compared to peers
Bell-curve outliers in E&M code distributionāparticularly clustering at higher complexity levelsāare a primary red flag for upcoding.
Question 3: What is the purpose of a 'segregation of duties' control in medical billing?
- To ensure no single employee can both post payments and adjust account balances, reducing embezzlement risk (Correct answer)
- To ensure all billing staff work in the same physical location
- To divide claims equally among all billers for efficiency
- To separate electronic claims from paper claims in the system
Correct answer: To ensure no single employee can both post payments and adjust account balances, reducing embezzlement risk
Segregation of duties prevents fraud by requiring different individuals to perform authorization, recording, and custody functions.
Question 4: A practice experiences ransomware that encrypts its billing system. According to HIPAA, when must HHS be notified if 600 patients' ePHI is affected?
- Within 60 days of discovering the breach (Correct answer)
- Immediately upon discovering the ransomware, within 24 hours
- Within 1 year if the data is recovered intact
- Only if the practice cannot restore data from backup
Correct answer: Within 60 days of discovering the breach
HIPAA Breach Notification Rule requires notification to HHS within 60 days of discovery for breaches affecting fewer than 500 individuals in a state.
Question 5: A risk assessment reveals that the billing software stores credit card numbers in plain text. Which control addresses this risk most directly?
- Implementing tokenization or encryption for stored cardholder data to meet PCI DSS requirements (Correct answer)
- Limiting the number of staff who can see the screen
- Adding a firewall to the network perimeter
- Requiring staff to change passwords every 30 days
Correct answer: Implementing tokenization or encryption for stored cardholder data to meet PCI DSS requirements
PCI DSS prohibits storing sensitive cardholder data in plain text; tokenization replaces card numbers with non-sensitive tokens.
Question 6: What does the term 'residual risk' mean after implementing billing software security controls?
- The risk that remains after all planned controls have been applied (Correct answer)
- The total cost of all security controls implemented
- The risk that was identified but removed from the risk register
- The probability of a breach before any controls are in place
Correct answer: The risk that remains after all planned controls have been applied
Residual risk is the exposure level that persists even after mitigating controls are deployed, and it must be accepted or further reduced.
Question 7: Which federal program requires healthcare providers to develop a compliance plan that includes billing risk assessment as a core component?
- The OIG Compliance Program Guidance for individual and small group physician practices (Correct answer)
- The Centers for Medicare & Medicaid Services (CMS) meaningful use program
- The Joint Commission accreditation standards
- The PCMH (Patient-Centered Medical Home) recognition program
Correct answer: The OIG Compliance Program Guidance for individual and small group physician practices
The OIG's Compliance Program Guidance specifically identifies risk assessment and internal audits as essential elements of an effective billing compliance program.
Medical Billing Software Risk Assessment & Management 4
A medical practice's billing software vendor is acquired by a competitor.
What risk management step should the practice take immediately?