Compliance & Regulatory Guidelines Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliance & Regulatory Guidelines flashcards as text
Which section of the Social Security Act governs civil monetary penalties for healthcare fraud, including submitting false claims to Medicare?
Answer: Section 1128A
Section 1128A of the Social Security Act authorizes the OIG to impose civil monetary penalties on individuals or entities that submit false or fraudulent claims to federal healthcare programs.
A Qui Tam lawsuit under the False Claims Act allows which party to file a lawsuit on behalf of the federal government?
Answer: Private whistleblower (relator)
Qui Tam provisions allow private individuals (relators or whistleblowers) to file FCA suits on the government's behalf and receive a portion of any recovery.
Under HIPAA's minimum necessary standard, when disclosing PHI for treatment purposes between treating providers, the standard:
Answer: Does not apply — treating providers may share complete records
HIPAA explicitly exempts disclosures for treatment purposes between treating providers from the minimum necessary standard, allowing complete clinical information sharing to support patient care.
A coder assigns diagnosis codes based on clinical indicators in the record without a physician's diagnosis. This practice is:
Answer: Generally prohibited — coders must code what physicians document
Coders must code diagnoses as documented by the treating physician; coding from clinical indicators without a physician diagnosis (except in specific UHDDS exceptions for inpatient coding) is improper.
What is the statute of limitations for the government to bring a civil action under the False Claims Act?
Answer: 6 years from the date of the violation, or 3 years from when the government knew/should have known (up to 10 years)
The FCA has a dual limitations period: 6 years from the violation date, or 3 years from when the government knew or reasonably should have known, whichever is later, but no more than 10 years.
Which Medicare audit program is specifically designed to measure the overall accuracy of Medicare fee-for-service payments on a national level by reviewing a statistically valid random sample of claims?
Answer: CERT
The Comprehensive Error Rate Testing (CERT) program measures the improper payment rate for Medicare FFS by reviewing a statistically valid random sample of claims paid during a given period.
An Advance Beneficiary Notice (ABN) is required to be given to Medicare patients when the provider believes Medicare will likely deny a service as:
Answer: Not medically necessary
An ABN must be issued when a provider believes Medicare may deny a claim for lack of medical necessity, allowing the patient to decide whether to receive and pay for the service.