Compliance and Regulatory Guidelines Flashcards
A provider consistently charges a higher level of E/M service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse, and why?
Fraud; the provider intentionally over-coded to gain financially.
According to this excerpt from the MUE table, which procedure can be reported with more than two units on the same date of service?
HCPCS/CPT Code MUE Values
15758 3
15760 2
15770 2
15775 1
15776 1
15777 1
15780 1
15758
Rationale: The MUE table identifies the maximum number of units a procedure can be reported on the same date of service. According to this table, 15758 can be reported with up to three units on the same date of service.
What does the MUE table indicate?
The maximum number of times a CPT®/HCPCS code should be reported on the same date of service for the same beneficiary.
A provider received a demand letter from the OIG initiating a Civil Monetary Penalty. The provider does not agree with the assessment from the OIG. What should the provider do?
Request a hearing before an HHS ALJ.
Rationale: The OIG will initiate the case by sending a demand letter outlining the CMP, assessment, and/or exclusions sought by the OIG, and the facts supporting the sanction. If the subject of the action disagrees, he/she can request a hearing before an HHS administrative law judge (ALJ).
What regulation is the penalty for violating the False Claims Act (FCA) increased by?
The Federal Civil Penalties Inflation Adjustment Act
Rationale: The statute originally provided for a civil penalty of not less than $5,000, and not more than $10,000, per claim, plus three times the amount of the government damages if FCA liability was found. This amount is occasionally increased based on the Federal Civil Penalties Inflation Adjustment Act (FCPIA).
What is CoP?
Medicare’s Conditions of Participation
Rationale: The Federal Register sets forth standards in Conditions of Participation (CoP) and Conditions for Coverage (CfC) that must be met to participate in Medicare and Medicaid Programs.
Under a CIA, 50 sampling units are selected for review. What is this sample referred to as?
Discovery sample
Rationale: Under a CIA, a Discovery Sample of 50 sampling units is randomly selected for review. This Discovery Sample is used to determine the net financial error rate.
When a physician is banned from participating in any Federal or State health care program by the OIG under the Exclusion Statute (42 U.S.C. § 1320a-7), what is the minimum term of exclusion that can be applied?
Five years
Rationale: According to 42 C.F.R. § 1001.102, the length of exclusion will not be less than five years.
When a Discovery Sample is performed, what error rate requires a Full Sample to be reviewed?
An error rate that exceeds five percent
What can a provider do if he or she disagrees with a demand letter sent as a result of a Recovery Audit?
Submit a discussion period request within 30 days of the date of the demand letter.
Rationale: If the provider disagrees with the demand letter, he or she may submit a discussion period request to the Recovery Auditor within 30 days from the date of the demand letter; submit a rebuttal to the MAC within 30 days from the date of the demand letter; or, submit a redetermination request to the MAC within 120 days from the date of the demand letter. This last option is the first level of appeal.
Which OIG publication is released monthly on the OIG website to identify various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General?
OIG Work Plan
Based on the compliance program guidance documents by the OIG, what should be documented when non-compliant conduct is found?
Date of incident, name of the reporting party, name of the person responsible for taking action, follow-up action taken.
The Federal False Claims Act provides the government can assess:
Up to three “times the amount of the damages which the Government sustains…”
Rationale: The government can assess up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, paid, solicited, or received.
You audit a provider who is consistently reporting multiple units of CPT code 11042. What references can you use to show the provider multiple units of CPT code 11042 are not allowed and explain how it should be reported?
CPT® codebook and MUE (Medical Unlikely Edits) table.
What is another name for the Federal False Claims Act (FCA)?
Lincoln Law
Rationale: Also called the Lincoln Law, the False Claims Act (31 U.S.C. §§ 3729 – 3733) was enacted in 1863 to combat fraud by suppliers of goods to the Union Army during the U.S. Civil War.
Recovery auditors may perform two types of reviews. What is an automated review?
Review based solely on the submitted claims and regulatory guidelines. No medical records are needed.
Rationale: For an automated review, no medical records are needed. Improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals.
What action would be considered fraud rather than abuse?
a. Increased level of E/M visits based on electronic health record documentation.
b. A provider utilizing modifier 25 on all E/M visits reported with a minor procedure.
c. A provider requiring the coding staff to intentionally code E/M services one level higher than documented.
d. A keying error.
c. A provider requiring the coding staff to intentionally code E/M services one level higher than documented.
Which of the following best represents an example of fraudulent activity?
A. Waiving cost-shares or deductibles
B. A pattern of claims for services not medically necessary
C. Billing for services at a higher level than provided or necessary
D. Failure to maintain adequate medical or financial records
C. Billing for services at a higher level than provided or necessary
Which CCM indicator allows a modifier to be appended to bypass an NCCI edit?
A CCM indicator of 1 indicates CCM is allowed and will bypass the edits.
Which option is considered a material breach of a CIA?
a. Failure to engage and use an IRO in accordance with the CIA.
b. Failure to hire an OIG employee to oversee compliance efforts.
c. Failure to hire a full-time internal auditor to review every claim before it is submitted.
d. Failure to fire auditors who do not agree with the provider’s coding.
a. Failure to engage and use an IRO in accordance with the CIA.
Rationale: Material breach of the agreement may result in an individual or entity being excluded from participation in any Federal health care program. Material breach is considered to be:
· Repeated or flagrant violation of the obligations under the corporate integrity agreement;
· Failure to report any reportable event, take corrective action, and make the appropriate refunds;
· Failure to respond to a Demand Letter concerning the payment of Stipulated Penalties; or
· Failure to engage and use an IRO in accordance with the agreement.
Recovery auditors may perform different types of reviews. What review requires medical records?
A complex review requires medical records. For an automated review, no medical records needed.
Which is considered Medicare abuse?
A. Misrepresenting the diagnoses to justify the payment?
B. Misusing codes on a claim
C. Billing for services at a higher level than provided or necessary
D. Altering claim forms to receive a higher payment
B. Misusing codes on a claim
A provider bills for tests on a new patient to rule out a medical condition. Based on the OIG compliance guidance, will Medicare pay for all tests ordered by the physician?
No, the tests must be reasonable and necessary to diagnose or treat a patient’s medical condition.
The Civil Monetary Penalty Law and the False Claims Act are revealed to which one of the following?
A. Combating fraud and abuse for Medicare and Medicaid
B. Mandating Regulations that govern privacy security for healthcare information
C. Proper claims filing
D. Mail fraud
C. Proper claims filing
