Chapter 1 - Review Flashcards
A physician received office space at a reduced rate for referring patients to the hospitals outpatient physical therapy center. What law does this violate?
Anti-Kickback Statute
Stark Law
False Claims Act
Truth in Lending Act
Anti-Kickback Statute
The Anti-Kickback law states that anyone who knowingly or willingly accepts items or services to induce referral is violating the law
Federal Healthcare Plans include what payers?
Blue Cross, Medicare, Humana
Medicare, Medicaid, Tricare
Medicare, Tricare, Blue Cross
Humana, VA, Tricare
Medicare, Medicaid, Tricare
Federal health care plans are any plans paid through government reimbursement
Medicare, Medicaid, Tricare, and VA programs are all administered by the Federal government
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?
-Physicians can bill the patient for services but cannot bill federal health plans
-Physicians can refer their patients to other facilities for treatment
-Physicians are prohibited from billing for any services to a federally administered health plan
-Physicians are exempt from billing for services but are allowed to write prescriptions and order tests
Physicians are prohibited from billing for any services to a federally administered health plan
An excluded individual cannot bill for services, provide referrals, prescribe medication, or order services for any beneficiary of a federally administered health plan
Includes Medicare, Medicaid, VA, & Tricare
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?
Fraud - subject to the Anti-Kickback Statute
Fraud - subject to the False Claims Act
Abuse - subject only to education of the provider
Abuse - subject to the Stark Law
Fraud - subject to the False Claims Act
Fraud is defined as making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal health care program
This creates unnecessary costs to the federal plan - in this example, billing for services that were not provided
The regulation of finance charges or interest applied to outstanding balances in medical practices are under what law?
Truth in Lending Act
Criminal Healthcare Act
HIPAA
Conditions of Participation
Truth in Lending Act
The Truth in Lending Act (Consumer Credit Protection Act) - designed to protect consumers dealing with lenders and creditors
What does the acronym PHI stand for?
Patient Healthcare Information
Patient History of Illness
Protected Health Information
Protected Healthcare Index
Protected Health Information
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?
Stark Law
HIPAAA
Anti-Kickback Law
Qui Tam
Anti-Kickback Law
Which of the following is NOT a component of the Preferred Provider Organization (PPO) payer model?
Offer a discounted fee schedule
Operate within networks
Require the enrollee to maintain a PCP
Utilization of preferred providers
Require the enrollee to maintain a PCP
Which of the following circumstances can PHI not be disclosed without the patient’s authorization or permission?
-An office receives a call from the patient’s husband asking for information about a recent office visit
-An office receives a court order
-An office receives requests for medical records for a Medicare audit
-An office releases patient information to the coroners office upon death of the patient
An office receives a call from the patient’s husband asking for information about a recent office visit
Which of the following is not a covered entity in the Privacy Rule?
Commercial insurance company
A healthcare consulting firm
A pediatric office
A billing service
A healthcare consulting firm
What types of entities do conditions of participation (CoP) apply to for health plans?
Hospitals
Clinics
Transplant Centers
Psychiatric hospitals
All the above
When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?
A code set
A transaction
A data set
Minimum Necessary
A transaction
According to the Privacy Rule, what must a business associate and covered entity have in order to do business?
-A mutually exclusive agreement describing the services that will be rendered by the business associate
-A notice of privacy
-A background check of both parties to ensure full disclosure
-A contract with specific safeguards on the individually identifiable health information used or disclosed by the business associate
A contract with specific safeguards on the individually identifiable health information used or disclosed by the business associate
A records request is received from a health plan for 3 dates of service in a chart months apart. What should the biller do?
-Copy the entire chart and send it to make sure that the health plan has everything they need and will not request more records
-Copy everything from the first date through the third date, even if it is not included to cover the time
-Copy each date of service and black out all identifying information in the copies before sending to the health plan
-Copy each date of service individually and send to the health plan
Copy each date of service individually and send to the health plan
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 breach
A Minimum Necessary Violation
A Disclosure Violation
Fraud
A breach
Which of the following situations allow the release of PHI without authorization from the patient?
Request for life insurance
Workers Compensation
Physicians office to release to a family member
Request from family member
Workers Compensation
What were the 8 standard transactions for electronic data interchange adopted under?
The Truth in Lending Act
HIPAA
The Social Security Act
Anti-Kickback Statute
HIPAA
A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?
An employee
A business associate
A covered entity
A clearinghouse
A business associate
HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?
CMS
Congress
HHS
AMA
HHS
If a provider is excluded from federal health plans, what does that mean?
-They may not participate in Medicare, but may participate in Medicaid to help the needy
-They may not participate in Medicare, Medicaid, VA programs, or Tricare
-They cannot bill for services, provide services, order services, or prescribe medication to any beneficiary of a federal plan
-They cannot bill for services or provide services, but may give Medicare patients referrals to receive services somewhere else
They may not participate in Medicare, Medicaid, VA programs, or Tricare
They cannot bill for services, provide services, order services, or prescribe medication to any beneficiary of a federal plan
According to the Privacy Rule, what health information may not be de-identified
Patient social security number
Medical record number
Patient home address
Physician provider number
Physician provider number
Health plans, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a:
Health entity
Business entity
Covered entity
Protected entity
Covered entity
Which of the following actions is considered under the False Claims Act?
Submitting claims for drugs
Filing incident-to claims
Releasing records w/out authorization
Upcoding or unbundling services
Upcoding or unbundling services
Individuals have the right to review and obtain copies of their PHI. What is excluded from the right of access?
Diagnosis
All lab results
Psychotherapy notes
Results of diagnostic tests
Psychotherapy notes
A practice sets up a payment plan with a patient. If more than 4 installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor?
Truth in Lending Act
False Claims Act
HIPAA
Social Security Act
Truth in Lending Act
What standard transaction is not included in EDI and adopted under HIPAA?
Referrals and authorizations
Eligibility in the health plan
Healthcare claim status
Waiver of liability
Waiver of liability
A practice agrees to pay $250,000 to settle a lawsuit alleging that the practice used X-rays of one patient to justify services on multiple other patients’ claims. The manager of the office brought the civil suit. What type of case is this?
Qui Tam
Stark Case
Anti-Kickback
HIPAA
Qui Tam
8 standard transactions were adopted for Electronic Data Interchange (EDI) under HIPAA. Which of the following is not included as a standard transaction
Payment and remittance advice
Eligibility in a health plan
Coordination of benefits
Physician unique identifier number
Physician unique identifier number
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?
-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)
-The records for the claim can be sent after authorization is received from the patient
-The entire patient record should be sent as part of HIPAA based on treatment, payment, and operations
-The payer is required to provide authorization signed from the patient prior to requesting the medical records
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)
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?
-The subpoena allows for the release of the medical records
-The subpoena is accompanied by a court order or the patient is notified and given a chance to object
-The individual must sign an authorization for release of the information
-Records cannot be released under any circumstance based on a subpoena
The subpoena is accompanied by a court order or the patient is notified and given a chance to object
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.
-The Security rule applies to health care providers, health plans, and any covered entity involved in the care of the patient
-The Security Rule applies only to the entity that initiates the release of protected health information
-Standards for storing and transmitting patient data in electronic form includes portable electronic devices
-The Security Rule states that safeguards must be in place to prevent unsecured release of information
The Security Rule applies only to the entity that initiates the release of protected health information
Health plans, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a
Health entity
Business entity
Covered entity
Protected entity
Covered entity
Medicare was passed into law under the title XVIII of what act?
HMO
Stabilization Act
HIPAA
Social Security Act
Social Security Act
OIG, CMS, and DOJ are the government agencies enforcing _
Federal fraud and abuse laws
HIPAA violations
Medical malpractice
Qui Tam violations
Federal fraud and abuse laws
Fraud and abuse penalties do not include
Monetary penalties
Exclusion from federal healthcare programs
Imprisonment
Ability to refile claims in question
Ability to refile claims in question
What entities are exempt from HIPAA and not considered to be covered entities
Workers Compensation
Sponsored group plans
Church sponsored plans
Employers with less than 100 employees
Workers Compensation
A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate?
The Fair Debt Collection Act
HIPAA
Federal Fraud Statute
The Truth in Lending Act
The Truth in Lending Act
A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?
-No, since the information is used for payment activities it is not necessary to notify or obtain authorization from the patient
-Yes, since PHI is being sent the patient must be notified and approve of the release
-No, because the office owns the medical record
-Yes, since it involves payment of a claim
No, since the information is used for payment activities it is not necessary to notify or obtain authorization from the patient
Medicare over payments should be returned within _ days after the over payment has been identified
30 days
120 days
60 days
1 year
60 days
What standard transaction is not included in EDI and adopted under HIPAA?
Referrals and authorizations
Eligibility in the health plan
Healthcare claim status
Waiver of liability
Waiver of liability
In addition to the standardization of the codes (ICD-10, CPT, HCPCS, and NDC) what other identifier is used on all claims?
Unique passcode
Unique identifier for employers and providers
Social Security number of provider
Social Security number of the office manager
Unique identifier for employers and providers
A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?
HIPAA
Stark
False Claims Act
Anti-Kickback
False Claims Act
A request for medical records is received for a specific date of service from the patient’s insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken?
-Request the signature for authorization from the patient
-Request a patient’s signature from the insurance company
-Release the requested records to the insurance company
-Release the records after receiving verbal permission from the patient
Release the requested records to the insurance company
HMO plans require the enrollee to
-Live in a specific geographic area
-See their provider quarterly
-To have referrals to see a specialist that is generated by PCP
-Go to the ER when unable to make appointment with PCP
To have referrals to see a specialist that is generated by PCP
A physician office (covered entity) discovers that the billing company (Business Associate) is in breach of their contract. What are the first steps to be taken?
-Contact HHS and report the billing company
-Terminate the contract
-Take steps to correct the problem and end the violation
-Contact your attorney
Take steps to correct the problem and end the violation
