AAPC CPB Chapter 1 Review QUESTIONS WITH COMPLETE SOLUTIONS

AAPC CPB Chapter 1 Review QUESTIONS WITH COMPLETE SOLUTIONS FCA Correct Answer: False Claims Act (FCA): {"knowing" and "knowingly"}-Federal statue setting civil and criminal penalties to protect the government from being overcharged or sold substandard goods or services: -falsely billing the government -over-representing the amount of a delivered product ....or.... -under-stating an obligation to the government Minimum Necessary Standard. What should be sent if records are being requested?? Correct Answer: The ? requires covered entities to take reasonable steps to limit the disclosure of PHI. Only the dates of service requested should be sent. The PHI would not need to be redacted. What does PHI stand for?? What does it include?? Correct Answer: Protected Health Information-"individually identifiable health information" that includes many common identifiers, such as demographic data, name, address, birth date, and social security number. If a provider is excluded from federal health plans, what does that mean?? Correct Answer: One of the most severe penalties associated with the Social Security Act is the ability of the Office of Inspector General (OIG) to exclude an entity or an individual from participation in any and all federal healthcare programs. This includes Medicare, Medicaid, VA programs, and TRICARE. An excluded individual cannot bill for services, provide referrals, prescribe medications or order services for any beneficiary of a federally administered health plan. HMO plans require the enrollee to?? Correct Answer: To have referrals to see a specialist that is generated by patient's PCP. HMO plans are managed and overseen by?? Correct Answer: The patient's PCP. The PCP is responsible to manage the referrals for panel of patients assigned to them. The Federal False Claim Act allows for claims to be reviewed for a standard of how many years after an incident?? Correct Answer: The federal False Claims Act (31 USC § 3729) allows for claims to be brought up to seven years after the incident, but has been extended to 10 years in some cases, but this is not the standard. What entities are exempt from HIPAA and not considered to be covered entities?? (3) Correct Answer: HIPAA allows exemption for entities providing only worker's compensation plans, employers with less than 50 employees as well as government funded programs such as food stamps and community health centers. What is the purpose of the Privacy Rule? Correct Answer: The purpose of the Privacy Rule is to protect individual privacy, while promoting high quality healthcare and public health and well-being. ______, _____, and _____ of Justice are the government agencies enforcing ________?? Correct Answer: The Department of Justice (DOJ), the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare and Medicaid (CMS) are the government agencies that enforce the Federal fraud and abuse laws. 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?? Correct Answer: The Anti-Kickback law-a federal law that makes it a criminal offense to knowingly or willingly offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal healthcare program. What are conditions of participation (CoP)?? What types of entities do CoP's apply to for health plans?? Correct Answer: CMS and other health plans have conditions that healthcare organizations must meet to participate with the plan or program. CoPs are designed to protect patient health and safety, and to ensure quality of care. These apply to entities such as: ambulatory surgical centers, hospitals, hospices, clinics, psychiatric hospitals, long term care facilities, and transplant centers. Patient questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party?? Correct Answer: HIPAA rules indicate that all entities should designate a Privacy Official that will develop and implement privacy policies and procedures and be a contact person for individuals with questions. According to the Privacy Rule, what health information may not be de-identified?? Correct Answer: Physician provider number. To de-identify health information, any information that could help identify the patient is removed. Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate and under what rule?? Correct Answer: The HIPAA Privacy Rule includes guidance for minimum necessary stating the use of PHI should be limited to the minimum necessary. When medical records are requested, records for only the date of service requested should be sent. A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?? Correct Answer: Business Associate +Perform certain functions or activities, which involve the use or disclosure of individually identifiable health information, on behalf of another person or organization. -These services include claims processing or administration, data analysis, utilization review, billing, benefit management, and re-pricing. Because the consultant will be auditing medical records, PHI will need to be shared from the practice. The practice would be the covered entity. Fraud and abuse penalties do NOT include?? Correct Answer: Ability to refile claims in question. +Fraud and abuse penalties are stiff and can include monetary penalties, exclusion from Medicare, Medicaid, and other federal healthcare programs and even imprisonment. A patient is seen in your clinic. Her husband calls later in the day to ask for information about the visit. The practice pulls the patient's privacy authorization to see if they can speak to the husband. What act does this action fall under?? Correct Answer: The Privacy Act is under HIPAA and protects the health information of the patient. According to HIPAA, for the practice to release information to the husband, the patient would have to have signed an authorization. What actions are considered under the False Claim Act? Correct Answer: Claims can be submitted for drugs unless the drugs were expired or were provided free to the entity. Incident-to claims are legal when the guidelines are adhered to. Releasing of records inappropriately are covered under the Privacy Rule. Relative to healthcare services, examples of fraud or misconduct subject to the False Claims Act include:- Falsifying a medical chart notation- Submitting claims for services not performed, not requ