CPC Compliance and Regulatory Rules 4 — Questions and Answers
Question 1: Which federal program allows private citizens (whistleblowers) to file lawsuits on behalf of the government and receive a portion of recovered funds?
- Anti-Kickback Statute
- Qui Tam provisions of the False Claims Act (Correct answer)
- Stark Law exceptions
- Civil Monetary Penalties Law
Correct answer: Qui Tam provisions of the False Claims Act
The False Claims Act's qui tam provisions allow private individuals (relators) to file suit on the government's behalf and receive 15-30% of recovered funds.
Question 2: A hospital provides free transportation services to Medicare patients to encourage them to use the hospital's services. This arrangement most likely violates:
- Stark Law only
- HIPAA Privacy Rule
- Anti-Kickback Statute (Correct answer)
- False Claims Act only
Correct answer: Anti-Kickback Statute
Offering free services to induce patient referrals to a Medicare-covered entity likely violates the Anti-Kickback Statute.
Question 3: Which of the following best describes 'medical necessity' in the context of Medicare billing compliance?
- Services the physician believes are appropriate regardless of guidelines
- Services that are reasonable and necessary for diagnosis or treatment of illness or injury (Correct answer)
- Any service requested by the patient
- Services covered by all insurance plans
Correct answer: Services that are reasonable and necessary for diagnosis or treatment of illness or injury
Medicare defines medical necessity as services or items that are reasonable and necessary for the diagnosis or treatment of illness, injury, or to improve functioning.
Question 4: A Corporate Integrity Agreement (CIA) is typically entered into between a healthcare provider and which federal agency?
- Centers for Medicare & Medicaid Services (CMS)
- Department of Justice (DOJ)
- Office of Inspector General (OIG) of HHS (Correct answer)
- Federal Bureau of Investigation (FBI)
Correct answer: Office of Inspector General (OIG) of HHS
CIAs are agreements between the OIG of HHS and healthcare providers as an alternative to exclusion from federal healthcare programs.
Question 5: What is 'excluded provider' status in the context of Medicare and Medicaid compliance?
- A provider who only accepts private insurance
- A provider barred from participation in federal healthcare programs (Correct answer)
- A provider who has opted out of Medicare
- A provider who treats only Medicaid patients
Correct answer: A provider barred from participation in federal healthcare programs
An excluded provider has been prohibited by the OIG from participating in Medicare, Medicaid, and other federal healthcare programs.
Question 6: Routine waiver of Medicare copayments and deductibles without determining financial hardship is considered fraudulent because it:
- Reduces the patient's out-of-pocket costs unfairly
- Inflates the true cost of services to Medicare
- Violates the patient's right to pay full charges
- Constitutes kickback inducements and misrepresents the actual charge (Correct answer)
Correct answer: Constitutes kickback inducements and misrepresents the actual charge
Routinely waiving cost-sharing can constitute an illegal inducement under the AKS and misrepresents the actual charge billed to Medicare.
Question 7: Under the Health Care Fraud and Abuse Control (HCFAC) program, which two agencies jointly administer the program?
- OIG and CMS
- DOJ and CMS
- HHS and DOJ (Correct answer)
- FBI and OIG
Correct answer: HHS and DOJ
The HCFAC program is jointly administered by the HHS Secretary and the Attorney General (DOJ) to combat healthcare fraud.
CPC Compliance and Regulatory Rules 4
Which federal program allows private citizens (whistleblowers) to file lawsuits on behalf of the government and receive a portion of recovered funds?