Practice Management & Billing Ethics Flashcards
6 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Practice Management & Billing Ethics flashcards as text
What is a 'corrected claim'?
Answer: A resubmission of a previously processed claim with corrections to specific data elements
A corrected claim is submitted when information on a previously processed claim was incorrect or incomplete, requiring specific bill type and frequency code changes.
What is 'waiving co-pays' and why is it considered a compliance risk?
Answer: Routinely not collecting required patient cost-sharing, which can violate payer contracts and anti-kickback laws
Routinely waiving co-pays without a documented financial hardship assessment violates payer contracts and may constitute fraud under the Anti-Kickback Statute.
What does 'timely filing' refer to in medical billing?
Answer: Submitting claims to payers within their specified deadline after the date of service
Timely filing limits are payer-specific deadlines for claim submission; claims received after the deadline are denied and typically cannot be appealed.
What is 'medical necessity' in the context of healthcare billing?
Answer: The requirement that services be reasonable and necessary for the diagnosis or treatment of illness or injury
Medical necessity requires that services be appropriate, covered by the payer, and consistent with evidence-based clinical standards to be eligible for reimbursement.
What is the purpose of staff training in a healthcare compliance program?
Answer: To ensure employees understand their compliance obligations, recognize risks, and know how to report concerns
Regular compliance training helps staff recognize fraud and abuse risks, understand regulations, and report violations, which is one of the OIG's seven elements of an effective compliance program.
What is an 'exclusion' under the OIG's List of Excluded Individuals and Entities (LEIE)?
Answer: A prohibition on an individual or entity from participating in federally funded healthcare programs
OIG exclusion prohibits individuals or entities from billing Medicare, Medicaid, or other federal programs; employing or contracting with an excluded party results in significant penalties.