CPB Final Exam with complete solutions

A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patients' claims. The office manager brought the civil suit. What type of case is this? - Answer- Qui Tam In which of the following circumstances may PHI not be disclosed without the patient's authorization or permission? - Answer- An office receives a call from the patient's husband asking for information about his wife's recent office visit. According to the Privacy Rule, what must a Business Associate and a Covered Entity have in order to do business? - Answer- A contract HMO plans require the enrollee to: - Answer- To have referrals to see a specialist that is generated by the patient's primary care provider. Which of the following is NOT a component of the PPO payer model? - Answer- Require the enrollee to maintain a Primary Care Provider. Under the Privacy Rule a health plan, clearinghouses, and any entity transmitting health information is considered? - Answer- Covered entity A request for medical records is received for a specific date of service from a patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken? - Answer- Release the requested records to the insurance company. Which of the following situations allows the release of PHI without authorization from the patient? - Answer- Workers' Compensation HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? - Answer- HHS What is the standard time frame established for record retention? - Answer- There is no single standard for record retention; it varies by state and federal regulations. CMS defines _______ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for a service that was not performed. - Answer- Fraud A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? - Answer- Abuse A person that files a claim for a Medicare Beneficiary knowing that the service is not correctly reported is in violation of what statute? - Answer- False Claims Act Which of the following actions is considered under the False Claims Act? - Answer- Up-coding or unbundling services A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? - Answer- Truth in Lending Act Medicare was passed into law under the title XVIII of what Act? - Answer- Social Security Act Which of the following statements are true regarding healthcare regulations? - Answer- Healthcare regulations may vary by state and by payer A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken? - Answer- Take steps to correct the problem and end the violation OIG, CMS, and the Department of Justice are the government agencies enforcing ______? - Answer- Federal fraud and abuse laws Fraud and Abuse penalties do NOT include: - Answer- Ability to re-file claims in question A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/GYN office they bill every patient for a urinalysis. What does this violate? - Answer- False Claims Act Individuals have the right to review and obtain