CH1- Introduction to Healthcare

Question 1

What do the government agencies OIG, CMS, and Department of Justice enforce?
A. Federal fraud and abuse laws
B. HIPAA violations
C. Medical malpractice
D. Qui tam violations

Answer 1

A. Federal fraud and abuse laws

Rationale: The Department of Justice (DOJ), the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare and Medicaid are the government agencies that enforce the federal fraud and abuse laws.

Question 2

A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every Medicare patient you send to them for radiology services. What does this offer violate?
A. HIPAA
B. Qui Tam
C. Anti-Kickback law
D. Stark Laws

Answer 2

C. Anti-Kickback law

Rationale: The Anti-Kickback law is a federal law that makes it a criminal offense to knowingly or willingly offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal healthcare program.

Question 3

Which of the following actions is considered under the False Claim Act?
A. Upcoding or unbundling services
B. Releasing records without authorization
C. Submitting claims for drugs
D. Filing Incident-to claims

Answer 3

A. Upcoding or unbundling services

Rationale: Claims can be submitted for drugs unless the drugs were expired or were provided free to the entity. Incident-to claims are legal when the guidelines are adhered to. Releasing of records inappropriately are covered under the Privacy Rule. Relative to healthcare services, examples of fraud or misconduct subject to the False Claims Act include:
- Falsifying a medical chart notation
- Submitting claims for services not performed, not requested, or unnecessary
- Submitting claims for expired drugs
- Upcoding and/or unbundling services
- Submitting claims for physician services performed by a non-physician provider (NPP) without regard to Incident-to guidelines

Question 4

Medicare overpayments should be returned within what time frame after the overpayment has been identified?
A. 1 year
B. 30 days
C. 120 days
D. 60 days

Answer 4

D. 60 days

Rationale: A provider must report and return an overpayment to the Secretary of HHS, the state, an intermediary, a carrier, or a contractor, as appropriate, by the later of 60 days from the date when the overpayment was “identified” or the date “any corresponding cost report is due.”

Question 5

Fraud and abuse penalties do NOT include which of the following?
A. Imprisonment
B. Monetary penalties
C. Exclusion from federal healthcare programs
D. Ability to refile claims in question

Answer 5

D. Ability to refile claims in question

Rationale: Fraud and abuse penalties are stiff and can include monetary penalties, exclusion from Medicare, Medicaid, and other federal healthcare programs and even imprisonment.

Question 6

What are health plans, clearinghouses, and any entity transmitting health information considered to be by the Privacy Rule?
A. Covered entity
B. Protected entity
C. Business entity
D. Health entity

Answer 6

A. Covered entity

Rationale: The Privacy Rule defines these as covered entities.

Question 7

What do HMO plans require of the enrollee?
A. Live in a specific geographic area
B. See their provider quarterly
C. Go to the ER when unable to make appointment with regular doctor
D. To have referrals to see a specialist that is generated by patient’s PCP

Answer 7

D. To have referrals to see a specialist that is generated by patient’s PCP

Rationale: HMO plans are managed and overseen by the PCP. The PCP is responsible to manage the referrals for a panel of patients assigned to them.

Question 8

According to the Privacy Rule, what health information may not be de-identified?
A. Medical record number
B. Physician provider number
C. Patient social security number
D. Patient home address

Answer 8

B. Physician provider number

Rationale: To de-identify health information, any information that could help identify the patient is removed.

Question 9

A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor?
A. HIPAA
B. Truth in Lending Act
C. False Claims Act
D. Social Security Act

Answer 9

B. Truth in Lending Act

Rationale: Truth in Lending Act (TILA) states practices who offer payment plans extending past four installments are considered lending institutions.

Question 10

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?
A. HIPAA
B. False Claims Act
C. Stark
D. Anti-kickback

Answer 10

B. False Claims Act

Rationale: CMS states that a false claim is made when someone knowingly presents or causes to be presented, a claim for payment of approval that is not legitimate.

Question 11

Which of the following is NOT considered Fraud?
A. Reporting a diagnosis code that the patient does not have, but is payable by Medicare
B. Billing every new patient at the highest-level E/M visit no matter what
C. Falsifying documentation to support a service that was billed to receive payment
D. Failure to maintain adequate medical records

Answer 11

D. Failure to maintain adequate medical records

Rationale: CMS defines fraud as making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program. CMS defines abuse as an action that results in unnecessary costs to a federal healthcare program, either directly or indirectly. CMS lists examples of abuse as: Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, and billing a Medicare patient a higher fee schedule than non-Medicare patients.

Question 12

The Federal False Claim Act allows for claims to be reviewed for how many years after an incident?
A. seven years
B. five years
C. three years
D. No timeline is defined

Answer 12

A. seven years

Rationale: The federal False Claims Act (31 USC § 3729) allows for claims to be brought up to seven years after the incident, but has been extended to 10 years in some cases, but this is not the standard.

Question 13

What does the acronym PHI stand for?
A. Patient History of Illness
B. Patient Healthcare Information
C. Protected Health information
D. Protected Healthcare Index

Answer 13

C. Protected Health information

Rationale: PHI stands for protected health information. PHI is “individually identifiable health information” that includes many common identifiers, such as demographic data, name, address, birth date, and social security number.

Question 14

Which of the following is not a covered entity in the Privacy Rule?
A. A Pediatric practice
B. A healthcare consulting firm
C. A billing service
D. Commercial insurance company

Answer 14

B. A healthcare consulting firm

Rationale: Covered entities are defined as health plans, healthcare clearinghouses, and any healthcare provider who transmits health information in an electronic format.

Question 15

What penalties can be imposed for fraud and/or abuse related to the United States code?
A. Monetary penalties ranging from $10,000 to $50,000 (before annual inflation adjustment) for each item or service
B. Imprisonment
C. Exclusion from federal healthcare programs
D. All of the above

Answer 15

D. All of the above

Rationale: Fraud and abuse carry stiff penalties under 42 USC § 1320a-7a of the United States code. Civil monetary penalties (CMPs) may be imposed to varying amounts, depending on the type of violation. Exclusion from participation in the federal healthcare programs and state healthcare programs may be imposed, along with criminal penalties of fines, imprisonment, or both.

Question 16

What were the eight standard transactions for electronic data interchange adopted under?
A. The Social Security Act
B. Anti-Kickback Statute
C. The Truth in Lending Act
D. HIPAA

Answer 16

D. HIPAA

Rationale: Under HIPAA, provisions were included for Administrative Simplification that mandated HHS to adopt national standards for electronic healthcare transactions and code sets. Eight standard transactions were adopted.

Question 17

What is the standard time frame established for record retention?
A. The life of the patient
B. Seven years
C. There is no single standard record retention, it varies by state and federal regulation
D. Five years

Answer 17

C. There is no single standard record retention, it varies by state and federal regulation

Rationale: There is no single standard record retention requirement, it varies by state and federal regulations. The five-year timeline is for CMS providers that submit cost reports. Seven years is the length of time that False Claims can be investigated.

Question 18

A physician office (covered entity) discovers that the billing company (Business Associate) is in breach of their contract. What is the first steps to be taken?
A. Contact HHS and report the billing company
B. Contact your attorney
C. Take steps to correct the problem and end the violation
D. Terminate the contract

Answer 18

C. Take steps to correct the problem and end the violation

Rationale: The covered entity should take steps to rectify the problem and end the violation. When it is not possible to rectify the problem, HHS Office of Civil Rights should then be contacted.

Question 19

What is the purpose of the Privacy Rule?
A. To keep provider information private
B. To keep payment amounts private
C. To protect facility information
D. To protect patient privacy

Answer 19

D. To protect patient privacy

Rationale: The purpose of the Privacy Rule is to protect individual privacy, while promoting high quality healthcare and public health and well-being.

Question 20

A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/Gyn office, they bill every patient for a urinalysis. What does this violate?
A. False Claim Act
B. Qui Tam action
C. Anti-kickback
D. Stark Law

Answer 20

A. False Claim Act

Rationale: Billing for services that were not performed is considered a violation of the False Claim Act.

Question 21

A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on to the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this?
A. Fraud
B. A disclosure violation
C. A breach
D. A minimum necessary violation

Answer 21

C. A breach

Rationale: A breach occurs when an impermissible release or disclosure of information is discovered.

Question 22

A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS?
A. False claim
B. Malpractice
C. Abuse
D. Fraud

Answer 22

C. Abuse

Rationale: CMS considers abuse to be actions that cause unnecessary costs to a federal healthcare program, either directly or indirectly. CMS examples of abuse:
- Misusing codes on a claim
- Charging excessively for services or supplies
- Billing for services that were not medically necessary
- Failure to maintain adequate medical or financial records
- Improper billing practices
- Billing Medicare patients a higher fee schedule than non-Medicare patients

Question 23

In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) what other identifier is used on all claim?
A. Social Security number of provider
B. Unique passcode
C. Social Security number of the office manager
D. Unique identifier for employers and providers

Answer 23

D. Unique identifier for employers and providers

Rationale: Providers of service have a unique provider identifier that is used on all claims called an NPI number.

Question 24

When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?
A. A data set
B. Minimum necessary
C. A transaction
D. A code set

Answer 24

C. A transaction

Rationale: A transaction is the electronic transfer of information between two parties for specific purposes.

Question 25

While working in a large practice, Medicare overpayments are found in several patient accounts. The manager states that the practice will keep the money until Medicare asks for it back. What does this action constitute?
A. Abuse
B. Qui Tam
C. Fraud
D. Good business

Answer 25

C. Fraud

Rationale: It is considered fraud under the False Claims Act. According to the False Claims Act, a person is liable if they act improperly to avoid paying money owed to the government. Medicare requires a provider to report and return any overpayment by the later of 60 days from the date the overpayment is identified or the date any corresponding cost report is due, along with an explanation.

Question 26

HIPAA of 1996 includes a Security Rule that is established to provide what national standards for protecting and transmitting patient data. Which of the following is NOT true?
A. The Security rule applies to healthcare providers, health plans, and any covered entity involved in the care of the patient.
B. The Security Rule applies only to the entity that initiates the release of protected health information.
C. Standards for storing and transmitting patient data in electronic form include portable electronic devices.
D. The Security Rule states that safeguards must be in place to prevent unsecured release of information.

Answer 26

B. The Security Rule applies only to the entity that initiates the release of protected health information.

Rationale: All entities are responsible for the protected health information, including the entity receiving the information. Portable electronic devices such as tablets and smart phones are to be made secure with passwords that are not shared between staff.

Question 27

Eight standard transactions were adopted for Electronic Data Interchange (EDI) under HIPAA. Which of the following is NOT included as a standard transaction?
A. Payment and remittance advice
B. Eligibility in a health plan
C. Coordination of benefits
D. Physician unique identifier number

Answer 27

D. Physician unique identifier number

Rationale: The physician unique identifier number is not included in the standard transactions, although it is to be included on the claim. Payment and remittance advice, eligibility in a health plan, and coordination of benefits all contain protected health information of the patient and are included in the transaction set.

Question 28

A claim is received by a payer that subsequently requests the medical records for the date of service on the claim. What procedure should be followed by the practice?
A. Only the date of service on the claim should be sent to the payer. The records can be sent as part of HIPAA based on treatment, payment, and operations (TPO).
B. The records for the claim can be sent after authorization is received from the patient.
C. The entire patient record should be sent as part of HIPAA based on treatment, payment, and operations.
D. The payer is required to provide authorization signed from the patient prior to requesting the medical records.

Answer 28

A. Only the date of service on the claim should be sent to the payer. The records can be sent as part of HIPAA based on treatment, payment, and operations (TPO).

Rationale: Medical records requested from a payer may be sent to the payer based on the Treatment, Payment, and Operations provision of HIPAA. However, in doing so, the Minimum Necessary provision should be followed and only the date of service requested should be sent.

Question 29

HIPAA requires that privacy practice notices be provided in several circumstances. Which one of the following is NOT required?
A. Must be available on any website the practice maintains
B. Must be provided upon request
C. Must be presented to all patients
D. Must be placed into the patient’s file

Answer 29

D. Must be placed into the patient’s file

Rationale: HIPAA states that the privacy practice should be available electronically on any websites they maintain, and presented to patients as they present for care, as well as providing a notice upon request. The notice does not need to be filed in the patient’s file, however the signature showing that the patient received the notice should be filed.

Question 30

When a subpoena is received by the practice for medical records, in what circumstances may the records be released according to the HIPAA Privacy Rule?
A. The subpoena allows for the release of the medical records.
B. The subpoena is accompanied by a court order or the patient is notified and given a chance to object.
C. The individual must sign an authorization for release of the information.
D. Records cannot be released under any circumstance based on a subpoena.

Answer 30

B. The subpoena is accompanied by a court order or the patient is notified and given a chance to object.

Rationale: A covered entity may disclose PHI required by a court order or administrative tribunal. A subpoena issued by a court clerk or an attorney in a case (someone other than a judge) is not synonymous with a court order. When a subpoena is issued, it should be accompanied by a court order to release the records. Only the records specified in the order may be disclosed. When the subpoena is not accompanied by a court order, the covered entity must make a reasonable effort to:

1.Notify the person who is the subject of the PHI about the request, giving them a chance to object to the disclosure; or to

2.Seek a qualified protective order for the information from the court.

Question 31

A physician received office space at a reduced rate for referring patients to the hospital’s outpatient physical therapy center. What law does this violate?
A. Anti-kickback statute
B. Stark law
C. False Claims Act
D. Truth in Lending Act

Answer 31

A. Anti-kickback statute

Rationale: The anti-kickback law states that anyone who knowingly or willingly accepts or offers any items or services to induce referral is a violation of the law.

Question 32

Federal healthcare plans include what payers?
A. Blue Cross, Medicare, Humana
B. Medicare, Medicaid, TRICARE
C. Medicare, TRICARE, Blue Cross
D. Humana, VA, TRICARE

Answer 32

B. Medicare, Medicaid, TRICARE

Rationale: Federal healthcare plans are any plans paid through government reimbursement—Medicare, Medicaid, TRICARE, and VA programs are all administered by the federal government.

Question 33

One of the most severe penalties that can be associated with violations of the Social Security Act is exclusion from federal healthcare plans. Which of the following statements is true of excluded individuals?
A. Physicians that have been excluded can bill the patient for services but cannot bill federal health plans.
B. Physicians that have been excluded can refer their patients to other facilities for treatment.
C. Physicians that have been excluded are prohibited from billing for any services to a federally administered health plan.
D. Physicians that have been excluded are exempt from billing for services but are allowed to write prescriptions and order tests.

Answer 33

C. Physicians that have been excluded are prohibited from billing for any services to a federally administered health plan.

Rationale: One of the most severe penalties associated with the Social Security Act is the ability of the Office of Inspector General (OIG) to exclude an entity or an individual from participation in any and all federal healthcare programs. This includes Medicare, Medicaid, VA programs, and TRICARE. An excluded individual cannot bill for services, provide referrals or prescribe medications or order services for any beneficiary of a federally administered health plan.

Question 34

A physician billed claims to Medicare and Medicaid for procedures that were not performed on 800 patients resulting in loss of $2.6 million. Is this fraud or abuse?
A. Fraud; subject to the anti-kickback statute
B. Fraud; subject to the False Claims Act
C. Abuse; subject only to education of the provider
D. Abuse; subject to the Stark law

Answer 34

B. Fraud; subject to the False Claims Act

Rationale: Fraud is defined as making false statements or making misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program. This creates unnecessary costs to the federal plan. In this example, billing was submitted for services that were not furnished or provided.

Question 35

The regulation of finance charges or interest applied to outstanding balances in the medical practice is under what law?
A. Truth in Lending Act
B. Criminal Healthcare Act
C. HIPAA
D. Conditions of Participation

Answer 35

A. Truth in Lending Act

Rationale: The Truth in Lending Act is also called the Consumer Credit Protection Act of 1968. The program is designed to protect consumers dealing with lenders and creditors.