Question 1

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Failure to make required refunds when services are not reasonable and necessary.

Accepted Answer

This is a case of insurance abuse, as the insurer is not fulfilling their specified obligations to refund for services that are deemed unreasonable or unnecessary. Fraud would be applicable if the insurer intentionally and knowingly withheld these refunds for their own financial gain.

Question 2

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Unbundling or exploding charges.

Accepted Answer

Unbundling or exploding charges is considered fraud because it involves intentionally manipulating billing codes to increase reimbursement from insurers or patients, which is a deliberate act of deception for financial gain.

Question 3

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Failure to make a refund when services are not reasonable or necessary.

Accepted Answer

This is a case of insurance abuse as the provider is not providing reasonable or necessary services, but it is not necessarily an intentional act to deceive or misrepresent information for financial gain, which is fraud.

Question 4

Match the positions below with the description of that person or entity.

-Individual who is designated to help a provider remain in compliance by setting policies and procedures in place, train staff regarding HIPAA Privacy guidelines, and act as the contact person for questions and complaints.

Accepted Answer

The individual described is a Privacy Officer, also known as Privacy Official. The Privacy Officer is responsible for ensuring compliance with HIPAA privacy guidelines and acts as a point of contact for related questions and complaints.

Question 5

Match the positions below with the description of that person or entity.

-A health care coverage carrier, clearinghouse, or physician who transmits health information in electronic form in connection with a transaction covered by HIPAA.

Accepted Answer

Covered entities under HIPAA include health plans, health care clearinghouses, and health care providers who electronically transmit any health information in connection with transactions for which the Department of Health and Human Services has adopted standards.

Question 6

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Forgiving the deductible or copayment for a Medicare patient.

Accepted Answer

Forgiving the deductible or copayment for a Medicare patient is considered fraud because it involves misrepresenting the actual charges to Medicare, which is illegal.

Question 7

To give, release, or transfer information to another entity is called consent.

Accepted Answer

To give, release, or transfer information to another entity is called disclosure. Consent is the permission given for disclosure.

Question 8

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Filing insurance claims for services not medically necessary.

Accepted Answer

Filing insurance claims for services not medically necessary is a case of insurance fraud.

Question 9

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Changing the date of service.

Accepted Answer

Changing the date of service on an insurance claim intentionally to deceive the insurance company or to gain benefits not entitled to is considered fraud. This act involves knowingly misrepresenting facts to obtain payment.

Question 10

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Altering fees on an insurance claim form to obtain higher payment.

Accepted Answer

Altering fees on an insurance claim form to obtain higher payment is considered fraud since it involves intentionally dishonest and deceitful behavior with the intent to deceive or obtain financial gain.

Question 11

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Charging excessively for services and supplies.

Accepted Answer

Charging excessively for services and supplies is a case of insurance abuse, as it involves providing services or supplies that are not necessary or are overpriced, rather than intentionally deceiving the insurance company as in fraud.

Question 12

The process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care services and regulate the industry is known as eHealth information management.

Accepted Answer

The process described in the statement is actually healthcare regulation and compliance. eHealth information management refers to the process of managing electronic health records and other health information using technology.

Question 13

Under HIPAA guidelines, a chiropractor or dentist's office would never be considered a covered entity.

Accepted Answer

Both chiropractors and dentists are considered covered entities under HIPAA guidelines, as they are healthcare providers who transmit healthcare information electronically.

Question 14

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Calling patients back for repeated and unnecessary follow-up visits.

Accepted Answer

This is a case of insurance abuse as the healthcare provider is utilizing excessive follow-up visits to increase the amount of reimbursement received from the insurance company. It does not involve intentionally deceiving the insurance company for financial gain, which would be considered insurance fraud.

Question 15

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Altering medical records to generate more in payment.

Accepted Answer

Altering medical records to generate more in payment is a clear case of insurance fraud, as it involves intentionally misleading the insurance company in order to receive more money.

Question 16

Match the positions below with the description of that person or entity.

-Individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business.

Accepted Answer

A health care provider is an individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business.

Answer: B
 A clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements.

Answer: C
 A covered entity is a health plan, health care clearinghouse or a health care provider that transmits any health information in electronic form.

Answer: D
 A business associate is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.

Answer: E
 A privacy officer or privacy official is an individual or entity responsible for the development and implementation of privacy policies and procedures for a covered entity.

Question 17

Match the positions below with the description of that person or entity.

-Third-party administrator who receives insurance claims from the physician's office, performs edits, and redistributes the claims electronically to various insurance carriers.

Accepted Answer

A clearinghouse is a third-party administrator that receives insurance claims from the physician's office, performs edits, and redistributes the claims electronically to various insurance carriers.

Question 18

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed.

-Billing Medicare beneficiaries at a higher rate than other patients.

Accepted Answer

Billing Medicare beneficiaries at a higher rate than other patients is considered abuse because it involves practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs to the Medicare Program. It is not fraud because it does not involve intentional deception or misrepresentation.

Question 19

Match the positions below with the description of that person or entity.

-Individual who is hired by a medical practice to process claims to a third-party payer.

Accepted Answer

A business associate is an individual or entity who performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.

Answer: B
 A clearinghouse is a third-party entity that processes healthcare transactions between providers and payers, such as insurance companies and government programs like Medicare and Medicaid.

Answer: A
 A healthcare provider is a person or entity that provides medical services, including doctors, nurses, hospitals, clinics, and other healthcare facilities.

Answer: C
 A covered entity is a person or entity that transmits health information in electronic form in connection with a healthcare transaction, such as healthcare providers, health plans, and healthcare clearinghouses.

Answer: E
 A privacy officer, also known as a privacy official, is a person responsible for ensuring compliance with privacy regulations in a healthcare organization. Their duties include developing privacy policies and procedures, training staff, and responding to privacy-related complaints and breaches.

Question 20

Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity.

Accepted Answer

Under HIPAA, an outside billing company that manages claims and accounts for a medical clinic is considered a business associate, not a covered entity. Covered entities are defined as health plans, health care clearinghouses, and health care providers who electronically transmit any health information in connection with transactions for which HHS has adopted standards.

Quiz 2: Compliance, Privacy, Fraud, and Abuse in Insurance Billing

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Failure to make required refunds when services are not reasonable and necessary.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Unbundling or exploding charges.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Failure to make a refund when services are not reasonable or necessary.

Match the positions below with the description of that person or entity. -Individual who is designated to help a provider remain in compliance by setting policies and procedures in place, train staff regarding HIPAA Privacy guidelines, and act as the contact person for questions and complaints.

Match the positions below with the description of that person or entity. -A health care coverage carrier, clearinghouse, or physician who transmits health information in electronic form in connection with a transaction covered by HIPAA.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Forgiving the deductible or copayment for a Medicare patient.

To give, release, or transfer information to another entity is called consent.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Filing insurance claims for services not medically necessary.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Changing the date of service.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Altering fees on an insurance claim form to obtain higher payment.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Charging excessively for services and supplies.

The process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care services and regulate the industry is known as eHealth information management.

Under HIPAA guidelines, a chiropractor or dentist's office would never be considered a covered entity.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Calling patients back for repeated and unnecessary follow-up visits.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Altering medical records to generate more in payment.

Match the positions below with the description of that person or entity. -Individual who renders medical services, furnishes bills, or is paid for health care in the normal course of business.

Match the positions below with the description of that person or entity. -Third-party administrator who receives insurance claims from the physician's office, performs edits, and redistributes the claims electronically to various insurance carriers.

Determine whether the following statements are cases of insurance (a) abuse or (b) fraud. You may use the two choices as many times as needed. -Billing Medicare beneficiaries at a higher rate than other patients.

Match the positions below with the description of that person or entity. -Individual who is hired by a medical practice to process claims to a third-party payer.

Under HIPAA guidelines, an outside billing company that manages claims and accounts for a medical clinic is known as a covered entity.