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

Question 1

What is the correct response when a relative calls asking about a patient?

A) Document the name of the relative and his or her relationship to the patient before disclosing any information.
B) Ask the relative to put the request in writing and include the patient's signed authorization.
C) Have the physician return the telephone call.
D) None of the above.

Answer 1

Have the physician return the telephone call.

Question 2

"What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about," is attributed to _________.

Answer 2

Hippocrates

Question 3

The Office of Civil Rights enforces

A) code set requirements.
B) insurance portability.
C) privacy and Security Rules.
D) HIPAA transactions.

Answer 3

privacy and Security Rules.

Question 4

A billing practice such as excessive referrals to other providers for unnecessary services is considered ________________________.

Question 5

Nonprivileged information consists of ordinary ____________________ unrelated to the treatment of the patient.

Question 6

Telephone conversations by providers in front of patients should be _____________________.

Question 7

Billing for services or supplies not provided is __________________.

Question 8

To bill Medicare beneficiaries at a higher rate than other patients is considered

A) negligence.
B) abuse.
C) fraud.
D) illegal.

Question 9

A health care organization must not conduct business with any health care provider who has been listed as an __________________ by OIG.

Question 10

Confidential information includes

A) everything that is heard about a patient.
B) everything that is read about a patient.
C) everything that is seen regarding a patient.
D) all of the above.

Question 11

Exceptions to the right of Privacy Rule include

A) patients carrying human immunodeficiency virus (HIV) or who have acquired immunodeficiency syndrome (AIDS).
B) gunshot wound cases.
C) all sexually transmitted disease cases.
D) all infectious disease cases.

Question 12

What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited?

A) Only the employee could be brought into litigation because it was he or she who actually performed the fraudulent act.
B) The employee could be exempt from litigation because the employee acted at the direction of the employer.
C) The employee and the employer could be brought into litigation by the state or federal government.
D) The employee and the employer could be brought into litigation by the local authorities and court.

Question 13

Stealing money that has been entrusted to one's care is known as ___________________.

Question 14

What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached?

A) Use care in the choice of words when leaving the message.
B) Do not leave a message.
C) Leave a complete message so that the patient will know why you called and be able to call you back and respond to anyone in the office.
D) Leave your name, the practice's name, and the practice's telephone number, but do not leave any other information.

Question 15

Nonprivileged information about a patient consists of the patient's

A) city of residence.
B) diagnosis.
C) illness.
D) treatment.

Question 16

Stark laws prohibit the submission of claims for "designated services" if the referring physician has a __________________ with the entity that provides the service.

Question 17

Confidentiality is automatically waived in cases of

A) gunshot wounds.
B) child abuse.
C) extremely contagious diseases.
D) all of the above.

Question 18

Identify which of the following would NOT typically be considered as a form of discipline for situations that involve fraudulent and malicious misconduct.

A) Verbal warning
B) Termination of employment
C) Restitution of any damages
D) Referral to federal agencies for criminal prosecution

Question 19

The focus on the health care practice setting and reducing administrative costs and burdens are the goals of

A) HIPAA Title I Insurance Reform.
B) HIPAA Title II Administrative Simplification.
C) HIPAA Security Rule Administrative Safeguard.
D) HIPAA Security Rule Technical Safeguard.

Question 20

When an insurance billing specialist bills for a physician and completes a Medicare claim form with information that does not reflect the true situation,

A) he or she may be subject to fines and imprisonment.
B) he or she may be found guilty of insurance abuse and sued.
C) only the physician can be held liable.
D) the insurance specialist cannot be prosecuted.

Question 21

What does "safe harbor" refer to?

Question 22

The key individual who oversees an organization's compliance program is referred to as the _________________.

Question 23

Name three measures that should be taken by a coder who has knowledge of fraud or abuse.

Question 24

List five of the disciplinary standards resulting from misconduct.

Question 25

List five specific risk areas identified by OIG that an office needs to monitor and follow.

Question 26

Define compliance.

Question 27

Under more recent legislation known as the Affordable Care Act, _________ compliance program requirements were implemented.

Question 28

Explain the difference between use and disclosure under HIPAA Privacy Rules.

Question 29

The Security Rule that addresses electronic protected health information is divided into which three main sections?

Question 30

Employees should be aware of what is expected from them and the consequences of misconduct through well-publicized ____________ guidelines.

Question 31

Health care organizations are encouraged to have a(n) ________________ policy to allow effective lines of communication whereby staff feel secure to report questionable or suspicious activities relating to fraud and abuse.

Question 32

List the six federal rights that patients are granted under the HIPAA Privacy Rules which allow them to be informed about PHI and to control how their PHI is used and disclosed.

Question 33

List three things that can be done to avoid having a patient hear confidential information regarding other patients.

Question 34

Explain when a physician's office would be considered a "covered entity."

Question 35

Employees should be required to attend a compliance training session at least __________.

Question 36

What is the goal of the Medicare Integrity Program (MIP)?

Question 37

The HIPAA amendments to the Criminal "FALSE" Claims Act cover what four areas?

Question 38

Since April 14, 2003, when privacy regulations became enforceable, providers are required to document which four things?

Question 39

List the seven basic components of a compliance plan.

Question 40

A well-designed compliance program should show a ______________ effort to submit claims appropriately.

Question 41

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.

A)Abuse
B)Fraud

Question 42

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.

A)Abuse
B)Fraud

Question 43

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.

A)Abuse
B)Fraud

Question 44

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.

A)Health care provider
B)Clearinghouse
C)Covered entity
D)Business associate
E)Privacy officer, privacy official

Question 45

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.

A)Health care provider
B)Clearinghouse
C)Covered entity
D)Business associate
E)Privacy officer, privacy official

Question 46

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.

A)Abuse
B)Fraud

Question 47

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

Question 48

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.

A)Abuse
B)Fraud

Question 49

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.

A)Abuse
B)Fraud

Question 50

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.

A)Abuse
B)Fraud

Question 51

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.

A)Abuse
B)Fraud

Question 52

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.

Question 53

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

Question 54

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.

A)Abuse
B)Fraud

Question 55

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.

A)Abuse
B)Fraud

Question 56

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.

A)Health care provider
B)Clearinghouse
C)Covered entity
D)Business associate
E)Privacy officer, privacy official

Question 57

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.

A)Health care provider
B)Clearinghouse
C)Covered entity
D)Business associate
E)Privacy officer, privacy official

Question 58

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.

A)Abuse
B)Fraud

Question 59

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.

A)Health care provider
B)Clearinghouse
C)Covered entity
D)Business associate
E)Privacy officer, privacy official

Question 60

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

Question 61

The Stark Law is commonly referred to as the Anti-Kickback statute.

Question 62

Submitting a claim for services that is not medically necessary is a violation of the False Claims Act.

Question 63

The Office of Civil Rights' (OCR) mission is to protect the integrity of the Medicare and Medicaid programs.

Question 64

Confidentiality between the physician and the patient is automatically waived when the patient is being treated in a workers' compensation case.

Question 65

Qui tam suits are those cases in which a private citizen known as a whistleblower reports a fraudulent activity within his or her organization.

Question 66

A HIPAA compliance exception to the right of privacy and privileged communication is a patient's records pertaining to his or her industrial accident case.

Question 67

Notes, papers, and memos regarding patient information should be disposed of using a shredding device.

Question 68

A patient has the right to obtain a copy of his or her confidential health information.

Question 69

The HITECH Act replaced the HIPAA privacy laws.

Question 70

Disclosing PHI as authorized by the laws relating to workers' compensation does not require a signed authorization.