Healthcare Compliance Exam Questions and Correct
Answers.
anti-kickback statute - Correct Answer The Social Security amendments of 1972 included
the original anti-kickback legislation the legislation stated the statute was to prevent fraud
and abuse from federal healthcare programs. A criminal statute that provides exchange of
anything of value in an effort to induce or reward the referral of federal healthcare program
business. If fined up to $25,000 and imprisonment up to five years
Safe harbors under anti-kickback statute? - Correct Answer Safe harbors immunize
certain payments and business practices that are implicated by the anti-kickback statute
from criminal and civil prosecution under the statute to be protected in a safe harbor and
arrangement must fit squarely in the safe harbor
Examples of safe harbors - Correct Answer Safe harbors include investments in
ambulatory surgical centers, joint ventures in underserved areas, practitioner recruitment
in underserved areas, sales a physician practices to hospitals in underserved areas,
subsidiaries for obstetrical malpractice insurance in underserved areas, investment in
group practices, specialty referral arrangements between providers, cooperative the
hospital service organizations
Seven elements of program for individual and small group physician practices - Correct
Answer The seven elements are conducting internal monitoring and auditing,
implementing compliance and practice standards, designating a compliance officer or
contact, conducting appropriate training and education, responding appropriately to
detected offenses and developing corrective action, developing open lines of
communication, and enforcing disciplinary standards through well-publicized guidelines
Benefits of a voluntary compliance program - Correct Answer Speed and optimize proper
payment of claims, minimize mistakes, reduce the chances that an audit will be conducted
by HCFA or that OIG and, avoid conflicts with the self referral and anti-kickback statute
Difference between erroneous and fraudulent claims to federal healthcare programs -
Correct Answer Fraudulent claims intentionally or recklessly are submitted to federal
healthcare programs. Erroneous claims are innocent errors submitted unintentionally to
federal healthcare programs
,What responsibility do healthcare providers have to federal healthcare programs? -
Correct Answer Federal healthcare providers have a duty to reasonably ensure that the
claim submitted to Medicare and other federal healthcare programs are true and accurate
What are the steps for auditing and monitoring evaluations - Correct Answer Ensure that
the standards and procedures are in fact current and accurate but also whether the
compliance program is working. following steps a standards and procedures review and
claim submission audit
What do you validate reviewing policies and procedures? - Correct Answer Validate they
are current and accurate if standards and procedures are found to be ineffective or
outdated they should be updated to reflect changes in government regulations or
compendiums generally relied upon by physicians and insurance for example CPT and
ICD-10 codes
Who should be involved in a claim submission audit? - Correct Answer The person in
charge of billing and a medically trained person to audit the records
What should physicians practice do if they are using another entities compliance
materials? - Correct Answer They need to tailor the materials to be applied by the
physician practice starting by the following, 1) develop written standards and procedures
2) updating clinical forms 3) make sure they facilitate encouraging clear and complete
documentation of patient care
What are the four basic risk areas developed by the OIG? - Correct Answer 1) coding and
billing 2) reasonable and necessary services 3) documentation 4) improper inducements
What are the biggest risks with coding and billing? - Correct Answer Billing for services not
rendered or provided by as claimed, submitting claims for equipment medical supplies and
services that are not reasonable and necessary, double billing resulting in duplicate
payments, billing for noncovered services as if covered, knowing misuse of a provider
identification numbers which results in improper billing, unbundling billing for each
component of service instead of billing for all inclusive code, failure to properly use Coding
modifiers, and a coding the level of service provided
What are the risks with the physician documentation? - Correct Answer The risks are
documentation is not performed timely and accurate. it is incomplete, it does not reflect
appropriate documentation of the diagnosis and treatment plan
,What are examples of internal documentation guidelines a practice could use? - Correct
Answer Examples of internal documentation guidelines are the medical record is complete
and legible, the documentation for each patient encounter includes the reason for the
encounter any relative history, physical examination, findings prior to diagnostic test
results, assessment clinical impression or diagnosis plan of care and date of legible
Identity of the other observer
What is one method for improving quality in documentation? - Correct Answer The method
is to compare the practices claim denial rate to the rates of other practices in the same
specialty to the extent of the practice can obtain that information from the carrier. Physician
coding and diagnoses distribution can be compared for each physician with the same
specialty to identify variances.
What are areas to monitor for that HCFA 1500 form? - Correct Answer Linking the
diagnosis code to the visit service, use of modifiers appropriately, provide Medicare with all
information about beneficiaries other insurance coverage under Medicare secondary
payer policy, improper inducements kickbacks and self referrals
Improper Inducements , Kickbacks and Self-Referrals. - Correct Answer Remuneration for
referrals is illegal because it can distort medical decision-making, cause overutilization of
services or supplies, increase costs to Federal health care
Areas to consider for improper inducements? - Correct Answer Financial arrangements
with outside entities to home practice may refer federal healthcare program business, joint
ventures with entity supplies goods or services to physician practice or its patients,
consulting contracts or medical directorship, office and equipment leases with entities to
which the physician refers, soliciting and excepting or offering any gift or gratuity for more
than nominal value to or from those who may benefit from the physician practice referral
What are the recommended record retention guidelines? - Correct Answer The length of
time that a practice records are to be retained specified in the standards and procedures
based on federal and state statute should be consulted, medical records if in the
possession of practice need to be secured against loss distruction, unauthorized access,
reproduction corruption or damage, standards and procedures can stipulate the
disposition of the medical records in the event the practice is sold or closed
What is the importance of compliance training? - Correct Answer 1) all employees will
receive training on how to perform their jobs in compliance with standards and practices in
any applicable regulations, 2) each employee will understand the compliance is a
, condition of continued employment 3) compliance training focuses on explaining why the
practice is developing a compliance program
What should be included in billing and coding training? - Correct Answer Coding
requirements, clean development and submission process, signing a form for a physician
without physician authorization, proper documentation of services rendered, proper billing
standards and procedures for submission to accurate bill for services to federal healthcare
program beneficiaries, the legal sanctions for submitting deliberate false a reckless billings
What steps are required to responding to detected offenses? - Correct Answer Corrective
action plan, the return of any overpayments, a report to the government, and or a referral
for law-enforcement authorities
A compliance program's open communication should include the following: - Correct
Answer The requirement employees conduct themselves in good faith, and report
anything to be fraudulent . The creation of user-friendly (such drop box for larger practices)
for effectively reporting conduct; Provisions procedures that state that failure report
erroneous or fraudulent conduct. compliance development of a simple and readily
accessible procedure to process fraudulent conduct; billing company is used,
communication to and from the billing company's compliance officer/contact and other
responsible staff to coordinate billing and compliance activities.
Advanced beneficiary notices, what are the requirements? - Correct Answer They must be
in writing, identify the specific service that may be denied with the CPT code and HCPCS
are required, stay in the specific reason why the physician believes that the service may be
denied, be signed by the patient acknowledging that the required information was provided
and the patient assumes responsibility to pay for the service
Physician Responsibilities to hospitals under EMTALA. - Correct Answer First, hospital
must conduct an appropriate medical screening examination to determine if an emergency
medical condition exists. Second, if the hospital determines that emergency medical
condition exists, it provide treatment necessary to stabilize the emergency medical
condition or comply with requirements to effect a proper transfer of a patient whose
condition has not been stabilized. Forth requirement if individual refuses hospital's offer of
additional examination treatment, or refuses transfer. A hospital may not transfer a patient
if the patient has not been stablized, Unless the patient or the representative makes a
written request for the transfer to be to another medical facility after being informed of the
risks to a physician has signed certification. The medical risks and benefits of a transfer
and certifying that based upon the information available at the time of transfer of the
medical benefits reasonably expected from the transfer outweigh the increased risks. 3) if
