Deck 5: Legal and Regulatory Issues

Question 1

Which consists of audits implemented by DHHS that examines the billing practices of physicians at teaching hospitals with the focus on compliance with the Medicare rule affecting payment for physician services provided by residents and whether the level of the physician service was coded and billed properly?

A) NCCI
B) PATH
C) SCHIP
D) ZPIC

Answer 1

PATH

Question 2

Which is a legal document containing a list of questions that must be answered in writing?

A) deposition
B) interrogatory
C) subpoena
D) subpoena duces tecum

Answer 2

interrogatory

Question 3

Which is the official document that contains new and changed Medicare policies and/or procedures that are to be incorporated into a specific CMS program manual?

A) bulletins
B) companion guides
C) face sheets
D) transmittals

Answer 3

transmittals

Question 4

Which is an order of the court that requires a witness to appear at a particular time and place to testify?

A) deposition
B) interrogatory
C) subpoena
D) subpoena duces tecum

Question 5

Which prohibits physicians from referring Medicare patients to clinical laboratory services in which the physicians or their family members have a financial ownership/investment interest and/or compensation arrangement?

A) False Claims Act
B) Federal Claims Collection Act
C) Privacy Act of 1974
D) Stark I

Question 6

Which is an abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, meaning "who as well for the king as for himself sues in this matter"?

A) qui tam
B) res gestae
C) respondeat superior
D) subpoena duces tecum

Question 7

Which is the physician self-referral law that protects patients and federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions?

A) Federal Anti-Kickback Law
B) Federal Claims Collection Act
C) Occupational Safety and Health Act
D) Social Security Act

Question 8

Criminal law is __________ law (statute or ordinance) that defines crimes and their prosecution.

A) administrative
B) case
C) civil
D) public

Question 9

Which was implemented to protect the privacy of individuals identified in information systems maintained by federal government hospitals and to give individuals access to records concerning themselves?

A) False Claims Act
B) Federal Claims Collection Act
C) Privacy Act of 1974
D) Stark I

Question 10

Because the diagnosis and procedure codes reported affect the DRG selected (and resultant payment), some hospitals engage in a practice called __________, which is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation, for the purpose of illegally increasing reimbursement.

A) downcoding
B) jamming
C) unbundling
D) upcoding

Question 11

Which requires Medicare administrative contractors to attempt the collection of overpayments received by a provider or beneficiary?

A) False Claims Act
B) Federal Claims Collection Act
C) Privacy Act of 1974
D) Stark I

Question 12

Which regulates fraud associated with military contractors selling supplies and equipment to the Union Army?

A) False Claims Act
B) Federal Claims Collection Act
C) Privacy Act of 1974
D) Stark I

Question 13

Civil law deals with all areas of the law that are not classified as __________ law.

A) administrative
B) case
C) criminal
D) standard

Question 14

Which is a legal newspaper published every business day by the National Archives and Records Administration (NARA), and is available in paper form, on microfiche, and online?

A) Coding Clinic
B) Code of Federal Regulations
C) Federal Register
D) Medicare Bulletin

Question 15

Federal and state __________ are laws passed by legislative bodies, such as federal Congress and state legislatures.

A) policies
B) procedures
C) regulations
D) statutes

Question 16

Which is testimony under oath taken outside of court, such as at the physician's office?

A) deposition
B) interrogatory
C) subpoena
D) subpoena duces tecum

Question 17

Court decisions establish standard use legal decisions that serve as authoritative rules or patterns in future similar cases. The legal term for standard is __________.

A) decision
B) example
C) precedent
D) statute

Question 18

Which requires documents, such as a patient record, to be produced in court?

A) deposition
B) interrogatory
C) subpoena
D) subpoena duces tecum

Question 19

Laws that are implemented as guidelines written by administrative agencies, such as CMS, are called __________.

A) policies
B) procedures
C) regulations
D) statutes

Question 20

Court decisions that establish a standard create __________ law.

A) administrative
B) admiralty
C) case
D) criminal

Question 21

Which amended Title IX of the Public Health Service Act to encourage voluntary and confidential reporting of events that adversely affect patients, creating organizations that collect, aggregate, and analyze confidential information reported by health care providers?

A) Deficit Reduction Act of 2005
B) Improper Payments Information Act of 2002
C) Patient Safety and Quality Improvement Act of 2005
D) Tax Relief and Health Care Act of 2006

Question 22

Which is a hospital payment monitoring program that contains hospital-specific administrative claims data for a number of CMS-identified problem areas to compare their performance with that of other hospitals?

A) CERT
B) FATHOM
C) PEPPER
D) PERM

Question 23

Which was implemented to assist with CMS audit, oversight, anti-fraud, and anti-abuse efforts related to the Medicare Part D benefit?

A) Hospital Inpatient Quality Reporting program
B) Medicare Integrity Program
C) Medicare Drug Integrity Contractors Program
D) Zone Program Integrity Contractor program

Question 24

Which created the Physician Quality Reporting System that established a financial incentive for eligible professionals who participate in a voluntary quality reporting program?

A) Deficit Reduction Act of 2005
B) Improper Payments Information Act of 2002
C) Patient Safety and Quality Improvement Act of 2005
D) Tax Relief and Health Care Act of 2006

Question 25

Which was established to require facilities to identify and reduce improper Medicare payments and the Medicare payment error rate and also established Clinical Data Abstracting Centers?

A) COBRA
B) PATH
C) PEPP
D) TEFRA

Question 26

Which are assigned to the MAC jurisdictions (replacing Program Safeguard Contractors) to review billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community?

A) hospital value-based purchasers
B) Recovery Audit Contractors
C) whistleblowers
D) Zone Program Integrity Contractors

Question 27

Which program measures, monitors, and reduces the incidence of Medicare fee-for-service payment errors for short-term, acute care, inpatient PPS hospitals?

A) CERT
B) FATHOM
C) HPMP
D) PERM

Question 28

Record retention is the __________ of documentation for an established period of time, usually mandated by federal and/or state law.

A) destruction
B) privacy and security
C) release
D) storage

Question 29

Which authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program?

A) COBRA
B) MIP
C) PEPP
D) TEFRA

Question 30

The Patient Protection and Affordable Care Act (PPACA) of 2010 includes a health care reform measure that requires implementation of the hospital __________ program to promote better clinical outcomes and patient experiences of care.

A) inpatient quality reporting
B) physician quality reporting
C) recovery audit contractor
D) value-based purchasing

Question 31

Which is a hospital payment monitoring program data analysis tool that provides administrative hospital and state-specific data for specific CMS target areas?

A) CERT
B) FATHOM
C) PEPPER
D) PERM

Question 32

HIPAA defines fraud as an __________ deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment.

A) accidental
B) intentional

Question 33

Which program was implemented to find and correct improper Medicare payments paid to health care providers participating in fee-for-service Medicare?

A) Hospital Inpatient Quality Reporting (Hospital IQR)
B) Medicaid Integrity Program (MIP)
C) Recovery Audit Contractor (RAC)
D) Zone Program Integrity Contractor (ZPIC)

Question 34

Which program assesses and measures improper Medicare fee-for-service payments (based on reviewing selected claims and associated medical record documentation)?

A) CERT
B) FATHOM
C) HPMP
D) PERM

Question 35

Which established the CERT, FATHOM, HPMP, PEPPER, and PERM programs?

A) Deficit Reduction Act of 2005
B) Improper Payments Information Act of 2002
C) Patient Safety and Quality Improvement Act of 2005
D) Tax Relief and Health Care Act of 2006

Question 36

Which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program, creating the Medicare Improvement Program (MIP)?

A) Deficit Reduction Act of 2005
B) Improper Payments Information Act of 2002
C) Patient Safety and Quality Improvement Act of 2005
D) Tax Relief and Health Care Act of 2006

Question 37

Which program provides consumers with quality of care information so they can make more informed decisions about health care options?

A) Hospital Inpatient Quality Reporting (Hospital IQR)
B) Medicaid Integrity Program (MIP)
C) Recovery Audit Contractor (RAC)
D) Zone Program Integrity Contractor (ZPIC)

Question 38

Which program measures improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP)?

A) CERT
B) FATHOM
C) HPMP
D) PERM

Question 39

The American Recovery and Reinvestment Act of 2009 (ARRA) protects whistleblowers, who are individuals that __________ covered by the Act.

A) are prosecuted for disclosing protected information
B) correct overpayments and other reimbursement issues
C) make specified disclosures relating to funds
D) receive remuneration for disclosing wrongdoings

Question 40

Which established the Hospital IQR, RAC, and ZPIC programs?

A) Deficit Reduction Act of 2005
B) Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
C) Patient Safety and Quality Improvement Act of 2005
D) Tax Relief and Health Care Act of 2006

Question 41

The Medicare Integrity Program includes medical review, which is defined by CMS as a review of claims to determine whether services provided are __________, as well as to followup on the effectiveness of previous corrective actions.

A) affordable by patient populations
B) covered by the Medicare program
C) effective for treatment of conditions
D) medically reasonable and necessary

Question 42

Which unique identifier is assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position?

A) EIN
B) HPID
C) NPI
D) UPIN

Question 43

An electronic signature will result in a unique bit string (or computer code) called a(n) __________, which is encrypted and appended to the electronic document.

A) electronic transaction
B) message digest
C) transmitted version
D) unique identifier

Question 44

Which of the following is an example of fraud?

A) billing noncovered services as covered services
B) falsifying certificates of medical necessity plans of treatment
C) reporting duplicative charges on an insurance claim
D) submitting claims for services not medically necessary

Question 45

Which code set is copyrighted by the American Dental Association?

A) CDT
B) CPT
C) ICD-10-CM
D) ICD-O-3

Question 46

Which unique identifier is assigned to third-party payers and has 10 numeric positions, including a check digit as the tenth position?

A) HPID
B) PAYERID
C) PlanID
D) UPIN

Question 47

HIPAA requires payers to implement rules called electronic __________, which result in a uniform language for electronic data interchange.

A) data interchanges
B) health records
C) medical records
D) transaction standards

Question 48

Which is the format of the EIN?

A) 000000000
B) 00-0000000
C) 000-00-0000
D) 000-000-000

Question 49

HIPAA defines abuse as involving actions that are __________ with accepted, sound medical, business, or fiscal practices, which directly or indirectly result in unnecessary costs to the program through improper payments.

A) compatible
B) inconsistent
C) recurrent
D) unvarying

Question 50

The proposed standard for an electronic signature is __________, which applies a mathematical function to the electronic document.

A) decrypted
B) digital
C) manual
D) standard

Question 51

Which is a variable-length file format used to bill institutional, professional, dental, and drug claims?

A) ANSI ASC X12N 837
B) CMS-1500
C) NSF
D) UB-04

Question 52

Drew Baker is referred to a health care provider by an employer for treatment of a fracture that occurred during a fall at work. The physician billed Medicare and did not indicate on the claim that the injury was work related. Medicare benefits were paid to the provider for services rendered. This resulted in Medicare contacting the provider, who is liable for the __________ because of the provider's failure to disclose that the injury was work-related.

A) adjudication
B) mediation
C) overpayment
D) unbundling

Question 53

The Patient Protection and Affordable Care Act established a Medicare shared savings program to facilitate the __________ to improve the quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary costs.

A) coordination and cooperation among health care providers
B) declining investment in infrastructure and redesigned care processes
C) lack of coordinated care for services under Medicare fee-for-service
D) reduction in accountability for the care of beneficiaries

Question 54

Encoding or __________ a computer file makes it safe for electronic transmission so that unauthorized parties cannot read it.

A) decrypting
B) digesting
C) encrypting
D) interchanging

Question 55

Which is maintained by the Food and Drug Administration (FDA) and identifies prescription drugs and some over-the-counter products?

A) CDT
B) ICD
C) NDC
D) NSF

Question 56

Which of the following is an example of abuse?

A) billing noncovered services/procedures as covered services/procedures
B) falsifying health care certificates of medical necessity plans of treatment
C) misrepresenting ICD-10-CM and CPT/HCPCS codes to justify payment
D) submitting claims for services and procedures knowingly not provided

Question 57

Any information communicated by the __________ is considered privileged communication, and HIPAA provisions address the privacy and security of protected health information.

A) patient to a health care provider
B) patient to a third-party payer
C) provider to a third-party payer
D) third-party payer to a provider

Question 58

Which was created by the Centers for Medicare and Medicaid Services for the purpose of assigning unique identifiers to health care providers and health plans?

A) CMS
B) DEEDS
C) EDI
D) NPPES

Question 59

Which flat file is a series of fixed-length records that is currently used to bill institutional services, such as services performed in hospitals?

A) ANSI ASC X12N 837
B) CMS-1500
C) NSF
D) UB-04

Question 60

Which flat file is used to bill physician and noninstitutional services, such as services reported by a general practitioner, on the CMS-1500?

A) CDT
B) EDI
C) NSF
D) UB-04

Question 61

Which involves the safekeeping of patient information by controlling access to records, protecting patient information from alteration/destruction/tampering/loss, and providing employee training in HIPAA requirements, which includes the consequences of improper disclosure of patient information?

A) authorization
B) confidentiality
C) privacy
D) security

Question 62

Breach of confidentiality involves the unauthorized release of patient information to a third party, such as health care employees who __________.

A) access patient health care information with an appropriate job-related reason
B) communicate patient information to family members with the patient's consent
C) discuss patient information outside an exam room where other patients are present
D) ensure that patient information is not available on a computer screen display

Question 63

Which specifically requires an individual's authorization prior to disclosure and for which HIPAA has established specific requirements for an authorization form?

A) covered entity data and information
B) designated record set
C) protected health information
D) treatment, payment, and operations

Question 64

The HIPAA Security Rule adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted __________.

A) electronically
B) manually
C) personally
D) physically

Question 65

Which is the right of individuals to keep their information from being disclosed to others?

A) authorization
B) confidentiality
C) privacy
D) security

Question 66

Release of information (ROI) by a covered entity about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information, which is reviewed for authenticity and processed within a HIPAA-mandated __________ time limit.

A) 10-day
B) 30-day
C) 60-day
D) 90-day

Question 67

Which restricts patient information access to those with proper authorization and maintains the security of patient information?

A) authorization
B) confidentiality
C) privacy
D) security

Question 68

Which documents patient information sent to authorized requestors and can be kept in manual or software formats?

A) decryption and encryption
B) electronic data interchange
C) release of information log
D) transmittals and manuals

Question 69

The HIPAA Privacy Rule creates national standards to protect individuals' medical records and other personal health information, and it also provides patients with __________.

A) conveniences, like not signing an authorization
B) greater access to their own medical records
C) less control over how their PHI is used
D) the ability to collect monetary penalties