Chapter 1 Flashcards
(32 cards)
Medicare was passed into law under the title XVIII of what Act?
Social Security Act
A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statute?
False Claims Act
According to the Privacy Rule, what must a Business Associate and covered entity have 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
OR
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 health plan sends a request for medical records 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.
What is Qui Tam?
A legal term that refers to a type of lawsuit where a private individual sues on behalf of the government.
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
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
If a provider is excluded from federal health plans, what does that mean?
I. They may not participate in Medicare, but may participate in Medicaid to help the needy.
II. They may not participate in Medicare, Medicaid, VA programs or TRICARE.
III. They cannot bill for services, provide services, order services, or prescribe medication to any beneficiary of a federal plan.
IV. They cannot bill for services or provide services, but may give Medicare patients referrals to receive services somewhere else.
II, III
The Federal False Claim Act allows for claims to be reviewed for how many years after an incident?
7 years
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?
Release the requested records to the insurance company - you do not need to notify the patient.
Which of the following penalties cannot be imposed for fraud and/or abuse related to the United States code?
Monetary penalties ranging from $10,000 to $50,000 (before annual inflation adjustment) for each item or service
Imprisonment
Exclusion from federal healthcare programs
Exclusion from all healthcare programs
Exclusion from all healthcare programs
How many national priority purposes are under the Privacy Rules for disclosure of specific PHI without an individual’s authorization or permission?
12
What were the eight standard transactions for electronic data interchange adopted under?
The Truth in Lending Act
Correct:
HIPAA
The Social Security Act
Anti-Kickback Statute
HIPAA
What do HMO plans require of the enrollee?
Live in a specific geographic area
See their provider quarterly
To have referrals to see a specialist that is generated by patient’s PCP
Go to the ER when unable to make appointment with regular doctor
To have referrals to see a specialist that is generated by patient’s PCP
HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?
HHS
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?
Fraud
Which of the following is NOT a component of the Preferred Provider Organizations (PPO) payer model?
Offer a discounted fee schedule
Operate within networks
Require the enrollee to maintain a PCP
Utilization of preferred plans
Require the enrollee to maintain a PCP
Give some examples of Stark Violations
Referring patients to a laboratory, clinic, or hospital owned by the physician or their spouse.
Buying or selling shares in an ambulatory surgery center at a steep discount.
Leasing equipment below fair market value.
“Per click” payment arrangements for equipment such as gamma knives, lithotripters, lasers, CT scanners, MRI machines, and more.
Sham directorships or ownership stakes in ASCs.
Hospitals, nursing homes, labs, dialysis centers, drug, or DME companies paying kickbacks to doctors through big salaries or “consulting” fees to serve as Medical Directors, proctors, or “consultants,” where the doctors do little actual, useful work.
Inappropriate compensation arrangements.
What are two key differences between the Stark Law and the Anti-Kickback Law?
- Anti-kickback refers to federal health plans
- The Stark law is strict liability - intent is not required.
Medicare overpayments should be returned within what time frame after the overpayment has been identified?
60 days
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
What is the standard time frame established for record retention?
There is no single standard record retention, it varies by state and federal regulation
What does the abbreviation HIPAA stand for?
What does the abbreviation HIPAA stand for?
What types of entities do conditions of participation (CoP) apply to for health plans?
I. Hospitals
II. Clinics
III. Transplant centers
IV. Psychiatric hospitals
All of these
