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 federal law established the Anti-Kickback Statute (AKS) that prohibits offering or receiving remuneration to induce referrals for Medicare/Medicaid services?
Answer: Social Security Act
The Anti-Kickback Statute is codified under the Social Security Act (42 U.S.C. § 1320a-7b) and prohibits remuneration intended to induce federal healthcare program referrals.
A coder assigns a higher-level E/M code than documentation supports to increase reimbursement. This practice is best described as:
Answer: Upcoding
Upcoding means billing a higher-level or more expensive service than was actually documented or provided, which constitutes fraud.
Under the Stark Law (Physician Self-Referral Law), which of the following is a designated health service (DHS) subject to its restrictions?
Answer: Clinical laboratory services
Clinical laboratory services are explicitly listed as a designated health service under the Stark Law, prohibiting self-referrals absent an applicable exception.
A Recovery Audit Contractor (RAC) identifies overpayments by reviewing Medicare claims. What is the RAC's payment model?
Answer: Contingency fee based on overpayments identified
RACs are paid on a contingency basis, receiving a percentage of the overpayments (and underpayments) they identify and recover.
Which OIG tool allows healthcare providers to voluntarily self-disclose potential fraud and abuse violations to avoid larger penalties?
Answer: Self-Disclosure Protocol (SDP)
The OIG's Self-Disclosure Protocol (SDP) allows providers to voluntarily report potential fraud, often resulting in reduced multipliers and penalties compared to government-initiated investigations.
What is the purpose of a National Coverage Determination (NCD) issued by CMS?
Answer: Determine whether Medicare covers a specific service nationally
An NCD is a CMS policy decision determining whether Medicare will cover a particular item or service across the entire country.
Which compliance document outlines the specific obligations a healthcare provider must meet as part of a settlement with the OIG following a fraud investigation?
Answer: Corporate Integrity Agreement
A Corporate Integrity Agreement (CIA) is a legal contract between the OIG and a provider settling a fraud case, specifying mandatory compliance obligations for a set period.