RHIT Healthcare Compliance and Regulations 3 — Questions and Answers
Question 1: The OIG Compliance Program Guidance recommends seven elements of an effective compliance program. Which element involves establishing clear lines of communication for reporting suspected violations?
- Written policies and procedures
- Effective lines of communication including a hotline (Correct answer)
- Regular auditing and monitoring
- Appropriate disciplinary action
Correct answer: Effective lines of communication including a hotline
Effective lines of communication, such as a confidential hotline, are one of the OIG's seven core compliance program elements.
Question 2: A coding professional unbundles a surgical procedure to maximize reimbursement. Under the National Correct Coding Initiative (NCCI), this practice is:
- Acceptable when a modifier is appended
- Prohibited because component codes are already included in the comprehensive code (Correct answer)
- Permitted for outpatient claims only
- Required when procedures are performed in separate sessions
Correct answer: Prohibited because component codes are already included in the comprehensive code
NCCI edits prohibit unbundling because component procedures are considered included in the comprehensive procedure code.
Question 3: Which federal agency is primarily responsible for investigating healthcare fraud and abuse under the Medicare and Medicaid programs?
- The Joint Commission
- Office of Inspector General (OIG) of HHS (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- Department of Justice Civil Division only
Correct answer: Office of Inspector General (OIG) of HHS
The OIG of HHS has primary authority to investigate fraud and abuse in Medicare and Medicaid and can impose exclusions and civil monetary penalties.
Question 4: A patient's psychotherapy notes are requested by their primary care physician. Under HIPAA, these notes:
- Can be released under the Treatment exception without authorization
- Require a specific authorization separate from a general medical records authorization (Correct answer)
- Are subject to the same rules as other medical records
- Must be released within 30 days of any clinical request
Correct answer: Require a specific authorization separate from a general medical records authorization
Psychotherapy notes receive heightened protection under HIPAA and require a specific patient authorization, separate from a general authorization.
Question 5: In the context of the Stark Law (Physician Self-Referral Law), which of the following is TRUE?
- It applies only to criminal referral arrangements
- It prohibits physician referrals for designated health services to entities in which the physician has a financial relationship, with limited exceptions (Correct answer)
- It only applies to Medicaid referrals
- It requires intent to defraud to establish a violation
Correct answer: It prohibits physician referrals for designated health services to entities in which the physician has a financial relationship, with limited exceptions
The Stark Law is a strict-liability civil statute prohibiting referrals for designated health services to financially related entities, with no intent requirement.
Question 6: A hospital's coding department finds a pattern of overcoding that resulted in overpayments from Medicare. Under the 60-Day Rule, the hospital must report and return the overpayment within 60 days of:
- The date the overpayment occurred
- The date the overpayment is identified (Correct answer)
- The end of the fiscal year
- The date the OIG issues a subpoena
Correct answer: The date the overpayment is identified
Under the 60-Day Rule (ACA Section 6402), overpayments must be reported and returned within 60 days of identification to avoid False Claims Act liability.
Question 7: Which accreditation organization's standards are most commonly used by hospitals seeking deemed status to meet CMS Conditions of Participation?
- National Committee for Quality Assurance (NCQA)
- URAC
- The Joint Commission (TJC) (Correct answer)
- Healthcare Facilities Accreditation Program (HFAP)
Correct answer: The Joint Commission (TJC)
The Joint Commission is the most widely recognized accrediting body, and its deemed status is accepted by CMS as meeting the Conditions of Participation.
RHIT Healthcare Compliance and Regulations 3
The OIG Compliance Program Guidance recommends seven elements of an effective compliance program.
Which element involves establishing clear lines of communication for reporting suspected violations?