PAR Regulatory and Compliance Standards 3 — Questions and Answers
Question 1: What is the primary purpose of the False Claims Act (FCA) in healthcare?
- To regulate patient discharge planning
- To penalize the submission of fraudulent claims to federal healthcare programs (Correct answer)
- To establish billing codes for outpatient services
- To require advance beneficiary notices for Medicare patients
Correct answer: To penalize the submission of fraudulent claims to federal healthcare programs
The False Claims Act imposes liability on individuals and organizations that submit false or fraudulent claims for payment to federal programs such as Medicare and Medicaid.
Question 2: An Advance Beneficiary Notice (ABN) must be given to a Medicare patient when:
- The patient is receiving a preventive service
- Medicare is likely to deny payment for a service due to medical necessity (Correct answer)
- The patient is admitted as an inpatient
- The patient requests a copy of their medical record
Correct answer: Medicare is likely to deny payment for a service due to medical necessity
An ABN is required when a provider believes Medicare will likely deny payment so the patient can decide whether to receive the service and accept financial responsibility.
Question 3: Which organization accredits hospitals and publishes quality performance data that patient access staff must be aware of for compliance purposes?
- CMS Office of Inspector General
- The Joint Commission (TJC) (Correct answer)
- Office for Civil Rights (OCR)
- National Committee for Quality Assurance (NCQA)
Correct answer: The Joint Commission (TJC)
The Joint Commission accredits and certifies healthcare organizations and programs, and its standards are widely used as a benchmark for quality and compliance.
Question 4: Under HIPAA's Minimum Necessary standard, when a staff member accesses PHI they should:
- Access the full medical record to ensure completeness
- Access only the information needed to accomplish the intended purpose (Correct answer)
- Print a copy for departmental files as a standard precaution
- Share access credentials with supervisors for oversight
Correct answer: Access only the information needed to accomplish the intended purpose
The Minimum Necessary standard requires that PHI disclosures and internal uses be limited to the least amount of information needed to accomplish the task.
Question 5: The OIG Exclusion List is important to patient access because:
- It lists patients who owe outstanding balances to Medicare
- Providers and employees on the list cannot participate in federal healthcare programs (Correct answer)
- It identifies hospitals with below-average quality scores
- It tracks physicians who have received malpractice settlements
Correct answer: Providers and employees on the list cannot participate in federal healthcare programs
Hiring or contracting with individuals or entities on the OIG Exclusion List can result in significant civil monetary penalties for the healthcare organization.
Question 6: Which of the following best describes the purpose of a hospital compliance program?
- To streamline the billing cycle for faster reimbursement
- To prevent, detect, and correct violations of laws, regulations, and internal policies (Correct answer)
- To manage patient grievances and satisfaction surveys
- To coordinate insurance authorization workflows
Correct answer: To prevent, detect, and correct violations of laws, regulations, and internal policies
A compliance program is designed to establish a culture of integrity and provide systematic processes to prevent, detect, and correct non-compliance with legal and regulatory requirements.
Question 7: A patient who is a minor presents to the ED without a parent or guardian. Under EMTALA, the hospital should:
- Refuse treatment until a guardian can be contacted
- Provide a medical screening examination and stabilizing treatment as necessary (Correct answer)
- Transfer the patient to a pediatric facility immediately
- Collect financial information before beginning the exam
Correct answer: Provide a medical screening examination and stabilizing treatment as necessary
EMTALA requires a medical screening exam and stabilizing treatment for all individuals presenting to the ED, including unaccompanied minors, due to the emergency exception to consent.
PAR Regulatory and Compliance Standards 3
What is the primary purpose of the False Claims Act (FCA) in healthcare?