CPC Compliance and Regulatory Guidelines 2 — Questions and Answers
Question 1: Which federal law established the False Claims Act, allowing the government to sue individuals or companies that defraud federal programs?
- HIPAA
- False Claims Act of 1863 (Correct answer)
- Stark Law
- Anti-Kickback Statute
Correct answer: False Claims Act of 1863
The False Claims Act of 1863 (updated in 1986) allows the government—and whistleblowers—to sue parties that knowingly submit false claims to federal programs like Medicare.
Question 2: Under HIPAA, which type of information is classified as Protected Health Information (PHI)?
- De-identified patient statistics used for research
- A patient's name combined with their diagnosis (Correct answer)
- Aggregate data from which no individual can be identified
- Anonymous survey responses about treatment outcomes
Correct answer: A patient's name combined with their diagnosis
PHI is individually identifiable health information that includes any data element that can link a person to their health condition, such as a name paired with a diagnosis.
Question 3: A coder bills a complex office visit when documentation only supports a straightforward visit to increase reimbursement. This is an example of:
- Unbundling
- Upcoding (Correct answer)
- Downcoding
- Fragmentation
Correct answer: Upcoding
Upcoding is reporting a higher-level service than what is documented or medically justified, which constitutes fraud.
Question 4: Which CMS program requires providers to report quality measures and can affect Medicare reimbursement rates?
- HIPAA Security Rule
- Merit-based Incentive Payment System (MIPS) (Correct answer)
- False Claims Act
- Stark Law Phase III
Correct answer: Merit-based Incentive Payment System (MIPS)
MIPS is part of the Quality Payment Program under MACRA and ties Medicare reimbursement adjustments to quality, cost, improvement activities, and promoting interoperability.
Question 5: What is the primary purpose of an Advance Beneficiary Notice (ABN)?
- To authorize a physician to provide emergency care
- To inform Medicare patients of services that may not be covered so they can decide whether to receive them (Correct answer)
- To obtain consent for sharing PHI with third parties
- To document medical necessity for inpatient admissions
Correct answer: To inform Medicare patients of services that may not be covered so they can decide whether to receive them
An ABN notifies Medicare beneficiaries before a service is rendered that Medicare may not pay, allowing them to make an informed financial decision.
Question 6: Which of the following best describes the 'qui tam' provision of the False Claims Act?
- It requires all healthcare providers to report known fraud to OIG
- It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds (Correct answer)
- It mandates annual compliance training for all hospital staff
- It establishes penalties for duplicate billing
Correct answer: It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds
Qui tam provisions enable private individuals (relators) to bring lawsuits on behalf of the government and receive a portion of any recovered damages.
Question 7: A hospital's compliance program discovers a billing error that resulted in overpayment from Medicare. Under the 60-day rule, what must the provider do?
- Report and return the overpayment within 60 days of identification (Correct answer)
- Correct the error internally without notifying CMS
- Apply the overpayment as a credit toward future claims
- Wait until the annual audit cycle to address the overpayment
Correct answer: Report and return the overpayment within 60 days of identification
The Affordable Care Act's 60-day rule requires providers to report and return Medicare/Medicaid overpayments within 60 days of identification or face False Claims Act liability.
CPC Compliance and Regulatory Guidelines 2
Which federal law established the False Claims Act, allowing the government to sue individuals or companies that defraud federal programs?