Healthcare Fraud and Abuse Flashcards
7 cards from real CHC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Fraud and Abuse flashcards as text
Which of the following arrangements would most likely qualify for the Anti-Kickback Statute 'employment safe harbor'?
Answer: A bona fide employee receiving a salary not based on referral volume
The employment safe harbor protects compensation paid by an employer to a bona fide employee for services in the employer's business, provided it is not based on the volume or value of referrals.
A compliance program audit reveals that a physician is billing Evaluation & Management (E&M) level 5 codes for almost all patient encounters. This pattern is BEST described as a potential indicator of:
Answer: Upcoding
Consistently billing the highest-level E&M codes regardless of the complexity of patient encounters is a classic pattern of upcoding.
The term 'medically unnecessary services' in the context of healthcare fraud most commonly refers to:
Answer: Services provided and billed that do not meet accepted standards of medical practice for the patient's condition
Billing for medically unnecessary services means billing for procedures or tests that are not reasonable and necessary for the patient's diagnosis or treatment under accepted clinical standards.
A whistleblower files a qui tam lawsuit under the False Claims Act. The government decides to intervene. What percentage of the total recovery can the relator (whistleblower) generally receive?
Answer: 10–25% (if the government intervenes) or 25–30% (if the government declines)
Under the FCA, relators in government-intervened cases receive 15–25% of the recovery; if the government declines and the relator proceeds alone, the share is 25–30%.
Which of the following is an example of 'credit card skimming' adapted to the healthcare context — i.e., a practice that involves billing the same service to multiple payers?
Answer: Duplicate billing
Duplicate billing involves submitting the same claim more than once to the same or different payers to receive multiple payments for a single service.
Under CMS's Medicare Fraud Prevention program, which tool allows Medicare beneficiaries to review their own claim data to identify potential fraud?
Answer: The Medicare Summary Notice (MSN) or MyMedicare.gov account
Medicare beneficiaries can review their claims through the Medicare Summary Notice or their MyMedicare.gov account to spot services they did not receive.
A hospital compliance officer is reviewing an arrangement where physicians receive 'facility fees' for office visits conducted in a newly designated provider-based department. The PRIMARY compliance concern is:
Answer: Whether the provider-based designation meets CMS requirements and whether patients are properly notified of additional costs
Provider-based billing allows facilities to charge facility fees, but CMS has strict requirements for provider-based status, and improper designation or lack of patient notification can constitute fraud.