Compliance and Regulatory Guidelines

Question 1

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?

Answer 1

Fraud; the provider intentionally over-coded to gain financially.

Question 2

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

Answer 2

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.

Question 3

What does the MUE table indicate?

Answer 3

The maximum number of times a CPT®/HCPCS code should be reported on the same date of service for the same beneficiary.

Question 4

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?

Answer 4

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).

Question 5

What regulation is the penalty for violating the False Claims Act (FCA) increased by?

Answer 5

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).

Question 6

What is CoP?

Answer 6

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.

Question 7

Under a CIA, 50 sampling units are selected for review. What is this sample referred to as?

Answer 7

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.

Question 8

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?

Answer 8

Five years

Rationale: According to 42 C.F.R. § 1001.102, the length of exclusion will not be less than five years.

Question 9

When a Discovery Sample is performed, what error rate requires a Full Sample to be reviewed?

Answer 9

An error rate that exceeds five percent

Question 10

What can a provider do if he or she disagrees with a demand letter sent as a result of a Recovery Audit?

Answer 10

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.

Question 11

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?

Answer 11

OIG Work Plan

Question 12

Based on the compliance program guidance documents by the OIG, what should be documented when non-compliant conduct is found?

Answer 12

Date of incident, name of the reporting party, name of the person responsible for taking action, follow-up action taken.

Question 13

The Federal False Claims Act provides the government can assess:

Answer 13

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.

Question 14

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?

Answer 14

CPT® codebook and MUE (Medical Unlikely Edits) table.

Question 15

What is another name for the Federal False Claims Act (FCA)?

Answer 15

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.

Question 16

Recovery auditors may perform two types of reviews. What is an automated review?

Answer 16

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.

Question 17

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.

Answer 17

c. A provider requiring the coding staff to intentionally code E/M services one level higher than documented.

Question 18

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

Answer 18

C. Billing for services at a higher level than provided or necessary

Question 19

Which CCM indicator allows a modifier to be appended to bypass an NCCI edit?

Answer 19

A CCM indicator of 1 indicates CCM is allowed and will bypass the edits.

Question 20

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.

Answer 20

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.

Question 21

Recovery auditors may perform different types of reviews. What review requires medical records?

Answer 21

A complex review requires medical records. For an automated review, no medical records needed.

Question 22

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

Answer 22

B. Misusing codes on a claim

Question 23

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?

Answer 23

No, the tests must be reasonable and necessary to diagnose or treat a patient’s medical condition.

Question 24

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

Answer 24

C. Proper claims filing

Question 25

Who is a Qui Tam relator?

Answer 25

A person who brings a civil action for a violation for him or herself and for the U.S. government

Question 26

What is one of the differences between the Stark law and the Anti-Kickback law?

A. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention.

B. No intent must be proven for the Anti-Kickback law; the Stark law requires proof of intention.

C. The Stark law refers to fraudulent billing; the Anti-Kickback law refers to remuneration for self-referrals.

D. The Anti-Kickback law refers to fraudulent billing; the Stark law refers to remuneration for self-referrals.

Answer 26

A. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention.

Question 27

When a physician is banned from participating in any federal or state healthcare 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?

Answer 27

Five Years

Question 28

What rights does a provider have if he or she disagrees with a demand letter sent by the OIG?

A. The provider can choose to self-disclose once a demand letter has been received.

B. The provider can send in supporting documentation for the claims to the OIG for review by certified mail.

C. The provider can only respond to the demand letter with payment.

D. The provider can request a hearing before an ALJ in the HHS.

Answer 28

D. The provider can request a hearing before an ALJ in the HHS.

Question 29

In a Corporate Integrity Agreement (CIA), does the OIG specify the Independent Review Organization to be used?

Answer 29

No; the OIG does not specify the IRO to be used but does retain the right to notify the provider if they must select a new IRO.

Question 30

When non-compliance is identified, what does the OIG recommend?

A. Take disciplinary action and document the date of the incident, name of the person responsible for acting, the follow-up action taken, and a list of claims that were affected by the action.

B. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for acting, and the follow-up action taken.

C. Immediately terminate employment for the party found in non-compliance, regardless of the severity of the offense, document the date of the termination, file a corrected claim on all claims affected.

D. Continue to watch the employee in non-compliance until the incidents meet a federal level before acting.

Answer 30

B. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for acting, and the follow-up action taken.

Question 31

When an IRO is completing a CIA Discovery Sample, how many sampling units are reviewed?

Answer 31

50

Question 32

The OIG lists potential risk areas for individual and small physician groups in the compliance plan guidance. Which option below is listed as a risk area?

A. Under-coding

B. Unbundling, (billing for each component of the service instead of billing or using an all-inclusive code)

C. Overuse of E/M codes

D. Failure to follow the “same-day” rule

Answer 32

B. Unbundling, (billing for each component of the service instead of billing or using an all-inclusive code)

Question 33

Which modifier indicator allows a modifier to be appended to bypass an NCCI edit?

A. 0
B. 1
C. 9
D. None

Answer 33

B. 1

Question 34

What does the MUE table indicate?

Answer 34

The maximum number of times a CPT®/HCPCS code should be reported on the same date of service for the same beneficiary.

Question 35

What method of communication is used by CMS to identify new or changed policies?

Answer 35

CMS utilizes online transmittals through the CMS Online Manual System.

Question 36

What is the goal of the Recovery Audit Contractor (RAC) program?

Answer 36

To identify improper payments of services submitted on Medicare claims by healthcare providers.

Question 37

What is an APM?

Answer 37

Advanced Alternative Payment Models (APM) is a group of clinicians who have voluntarily come together in an organized way to deliver coordinated high-quality care to Medicare patients.

Question 38

What is the goal of Merit-Based Incentive Payment System (MIPS)?

Answer 38

To provide a single quality reporting system with a single payment adjustment factor based on individual or group performance in Medicare Part B