Insurance Policies and Payments Flashcards
Case question: a pt receives a prescription from his doctor, the pt forges the rx to receive additional doses of the medications. Although the pt uses the medication to treat his symptoms, he also sells the additional doses of medication. How can this type of member fraud be prevented?
a. Report lost or stolen rx pads and or fraudulent rxs
b. Validate member ID cards
c. Bill for additional treatment
d. Submit treatment forms
Report lost or stolen rx pads and or fraudulent rxs
The privacy rule has two approaches to protecting the privacy of health info. One of these approaches includes:
a. Health care clearinghouses
b. Rights of individual patients to be provided with control over their own health information
c. Security, both administrative and physical, of protected health info.
d. Use and disclosure of PHI/Individually identifiable health info.
Rights of individual patients to be provided with control over their own health information
What is an example of an anti-kickback statute violation?
a. A physician refers a beneficiary to a clinic with the physician has an invested interest
b. A provider receives cash for medical office space in exchange for referrals
c. A physician knowingly submits claims t Medicare for medical services not provided
d. Authorizes OIG to seek CMPs for a variety of healthcare fraud violations:
A provider receives cash for medical office space in exchange for referrals
The security rule requires reasonable and appropriate administrative, technical, and physical safeguards for protecting ePHI. Which is an example of a Technical Safeguard:
a. Educate and Train
b. Establish emergency policies
c. Establish proper use policies
d. Establish electronic review procedures
Establish electronic review procedures
There are federal laws and governing bodies that regulate fraud and abuse in Medicare. Which of the following agencies enforce these laws? Select all that apply.
a. US Dept of Justice
b. US Dept of Health and Human Services
c. Centers of disease control and Prevention
d. Centers for Medicare and Medicaid Services
DOJ, HHS, CMS
The Federal Civil False Claims Act (FCA) protects the Federal Government from being overcharged or sold substandard goods or services. Which is an example of an FCA violation?
a. A provider accidentally uses wrong codes
b. A physician refers a beneficiary to a clinic where the physician has an investment interest
c. A physician knowingly submits claims to Medicare for medical services not provided
d. A provider receives cash from medical office space in exchange for referrals
A physician knowingly submits claims to Medicare for medical services not provided
Which of the following is an example of member fraud?
a. Forging a prescription, medical record, or referral form
b. RX drug switching
c. Excessive charges for services]
d. Offering bribes
Forging a prescription, medical record, or referral form
Payers trust that medically necessary, cost-effective, and quality care will be provided by the physician. Examples of improper claims include?
a. Billing for services performed with qualified employees
b. Billing services performed by an employee excluded from participation in the Federal Health care program
c. Billing for services provided
d. Billing for medically necessary services
billing services performed by an employee excluded from participation in the Federal healthcare programs.
A covered entity is permitted to use and disclose PHI for treatment, payment, and healthcare operations activities. Which is an example of payment activities?
a. Administrative and quality improvident activities that are necessary to run its business
b. Business planning and development
c. The management of health care and related services among health care providers
d. Obtaining premiums, providing benefits and the plan, and providing reimbursement for the provision of health care
Obtaining premiums, providing benefits and the plan, and providing reimbursement for the provision of health care
In the Security Rule, covered entities must?
a. Voluntarily choose to obtain the individual’s consent to use and disclose information
b. Agree to anyone’s request for PHI
c. Ensure the confidentiality of all electronic health records
d. Have open access to any and all PHI requests
Ensure the confidentiality of all electronic health records
