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When non-compliance is identified, what does the OIG recommended? a .Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action,and the follow-up action taken. c. Immediately terminate employment for the party found in non-compliance,regardless of the severity of the offense,document the date of the termination,file a corrected claim on all claims affected. d. Continue to watch the employee in non-compliance until the incidents meet a federal level before taking action. - b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action,and the follow-up action taken A provider consistently charges a higher level E/M service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse Why? a. Abuse,charging one level higher on each visits does not show intent. b. Abuse; the provider's practice is common and therefore would not be considered fraudulent. c. Fraud; and over-coding of services would be considered fraudulent.
d. Fraud; the provider intentionally over-coded to gain financially. - d. Fraud; the provider intentionally over-coded to gain financially. The OIG lists potential risk areas for individual and small physician groups in the compliance plan guidance. Which option below is listed as a risk area? a. Unbundling b. Under Coding c. Overuse of E/M codes d. Failure to follow the "same day" rule - a. Unbundling The FCA allows for reduced penalties if the person in violation self-discloses if which conditions exist? a. The person furnishes all information about the violation with in 30 days after which the defendant first obtained the information. b. The person fully cooperates with the investigation. c. There is no additional criminal prosecution, civil action, or administrated action with the respect to the violation. d. All of the above - d. All of the above
d. The provider must apply for a group provider number. - b. The provider must apply for reinstatement Which option is considered a material breach of CIA? a. Failure to engage and use an IRO in accordance with the CIA. b. Failure to hire an OIG employee to oversee compliance efforts. c. Failure to hire a full-time internal auditor to review every claim before it is submitted. d. Failure to fire auditors who do not agree with the provider's coding - a. Failure to engage and use an IRO in accordance with the CIA. CMS has two sets of Evaluation and Management Documentations Guidelines , 1995 and 1997. Which set is used by physicians for office visits? a. 1995 E/M Documentation Guidelines b. 1997 E/M Documentation Guidelines c. The practice must choose either the 1995 or 1997 E/M Documentation Guidelines for the entire practice. d. The practice may use 1995 or 1997 E/M Documentation Guidelines for each visit; whichever is most advantageous for that visit. - d. The practice may use 1995 or 1997 E/M Documentation Guidelines for each visit; whichever is most advantageous for that visit.
What is a semi-automated review? a. a review based on electronic data examined form submitted claims. b. A review based on electronic data examined from submitted claims but electively supported by medical records sent by the provider. c. a review based on complete medical records review due lack of Medical Policy being in a place d. a review based on tips sent in from internal informants. - b. A review based on electronic data examined from submitted claims but electively supported by medical records sent by the provider. Which option is NOT part of the seven elements that should be included in a compliance plan based on the OIG's recommendations? a. Conducting effective training and education. b. Responding promptly to detected offenses and developing corrective action. c. Identifying employees on the exclusions list. d. Developing effective lines of communication - c. Identifying employees on the exclusions list. What can a provider do if he or she disagrees with a demand letter sent as a result Recovery Audit?
b. Hire an OIG employee to oversee the compliance efforts c. Develop written standards and policies d. Restrict employment of ineligible persons. - b. Hire an OIG employee to oversee the compliance efforts Recovery auditors may perform three types of reviews. What review requires medical records? a. Automated b. Semi Automated c. Complex d. Independent - d. Independent In NCCI edits, what does modifier indicator zero represent? a. A modifiers is not allowed to bypass the NCCI edits. b. A modifier may be used to bypass the edits if the documentation supports the modifier. c. Modifiers are not applicable to the edits. d. The NCCI edits is not in effect. - a. A modifiers is not allowed to bypass the NCCI edits
What is one of the differences between the Stark Law and the Anti-Kickback Law? a. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention. b. No intent must be proven for the Anti-Kickback law The Stark law requires proof of intention. c. The Stark law refers to fraudulent billing; the Anti-Kickback law refers to remuneration for self referrals. d. The Anti-Kickback law refers to fraudulent billing; the Stark law refers to remuneration for self referrals. - a. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention. What is another name for the Federal False Claims Act? a. Operation Restore Trust b. Kennedy-Kassebaum Law c. Lincoln Law d. Stark Law - c. Lincoln Law According to this excerpt from the MUE table, which procedure can be reported with more than two units on the same date of service?
c. Medical records are required for review d. Review is based solely on denials received. - a. Review based solely on the submitted claims and regulatory guidelines. No medical records are needed. Which of the following best represents and example of fraudulent activity? a. Waiving cost-shares or deductibles. b. A pattern of claims for services not medically necessary. c. Failure to maintain adequate medical or financial records. d. Billing for services at a higher level than provided or necessary. - d. Billing for services at a higher level than provided or necessary. What rights does a provider have if he/she disagrees with a demand letter sent by the OIG? a. The provider can choose to self-disclose once a demand letter has been received. b. The provider can send in supporting documentation for the claims to the OIG for review by certified mail. c. The provider can only respond to the demand letter with payment. d. The provider can request a hearing before and ALJ in HHS. - d. The provider can request a hearing before and ALJ in HHS.
When an IRO is completing a CIA Discovery Sample, how many sampling units are reviewed? a. 10 b. 50 c. 100 d. 200 - b. 50 In the NCCI edits, what does modifier indicator one represent? a. A modifiers is not allowed to bypass the NCCI edits b. A modifier may be used to bypass the edits if the documentation supports the modifier. c. Modifiers are not applicable to the edits. d. The NCCI edit is not in effect. - b. A modifier may be used to bypass the edits if the documentation supports the modifier. What program is provided by the OIG to assist in random selection of charts for Discovery Sample? a. The OIG provides an on-site investigator to randomly select the charts for the Discovery Sample.
c. The maximum number of times PT/HCPCS code should be reported on the same date of service for the same beneficiary. d. The maximum number of times a CPT/HCPCS code should be reported within one year for the same beneficiary. - c. The maximum number of times PT/HCPCS code should be reported on the same date of service for the same beneficiary. Which statement is TRUE regarding 1995 and 1997 E/M Documentation Guidelines? a. The 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine evels of exams. b. The 1995 E/M Documentation Guidelines are never beneficial for specialists. c. The 1997 E/M Documentation Guidelines are beneficial for general practitioners. d. The 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. - d. The 1997 E/M Documentation Guidelines are more detailed using bullets and shading to determine levels of exams. Which OIG publication is released every year to identify various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections , Office of investigations, and Office of Counsel to the Inspector General? a. OIG Work Plan b. Semiannual Report to Congress
C. Compendium of Unimplemented Recommendations d. OIG Complaince Plan Guidance - a. OIG Work Plan Which CCM indicator allows a modifier to be appended to bypass an NCCI edits? a. 0 b. 1 c. 9 d. None - d. None In the NCCI edits, what does modifier indicator nine represent? a. A modifier is not allowed to bypass the NCCI edits b. A modifier may be used to bypass the edits if the documentation supports the modifier c. Modifiers are not applicable he edits, the NCCI edit is not in effect d. Only modifier 59 can be used to bypass the edit. - c. Modifiers are not applicable he edits, the NCCI edit is not in effect
b. 15,000 per item or service. c.10,000 per item or service plus three times the amount of over-payments. d. 15,000 per item or service plus three ties the amount of over-payments. - c.10,000 per item or service plus three times the amount of over-payments. The OIG Work Plan is divided into seven parts. Which option is a part of the OIG work plan most applicable to physician? a. Medicare Part A and Part B b. Public Health Reviews c. Human Services Reviews d. Corporate Integrity Agreements - a. Medicare Part A and Part B You Audit provider who is consistently reporting multiple units of CPT code 11042. What references can you use to show the provider multiple units of CPT code 11042 is not allowed and explain how it should be reported? a. CPT codebook and MUE table. b. CPT codebook and NCCI edits
c. MUE table only d. HCPCS codebook and NCCI edits - a. CPT codebook and MUE table The OIG determines a provider is guilty of submitting 10 fraudulent claims resulting in $25, in over payments made to the provider. What is the maximum penalty the OIG may seek? a.$ 75, b. $100, c. $125, d. $175,000 - d. $175, Which governing body is responsible for criminal prosecutions relating to the Privacy Rule? a. Office if Civil Rights b. Secretary of State c. Office of Inspector General d. Department of Justice - d. Department of Justice What standard does the Privacy Rule set?
d. When the covered entity has policies and procedures in place to identify each person who has incidentally had access to the record. - c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. How long does HIPPA required medical records to be maintained? a. Five years from the date of its creation or the date from which it was last in effect ( whichever is later) b. Six years from the date of its creation or the date from which it was last in effect ( whichever is later) c. Ten years from the date of its creation or the date from which it was last in effect ( whichever is later) d. Five years past the date of death of the patient - b. Six years from the date of its creation or the date from which it was last in effect ( whichever is later) What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of medical record? a. Established their own standards b. Not put any in place
c. Call HHS and ask for clarification d. Continue practicing without guidance until an issue arises. - a. Established their own standards In evaluation and management services, what does the S stand for in SOAP? What is included in this section? a. Standard; indicates this is a standard format. b. Story; the provider documents the patient's story about his or her life. c. Subjective; patient's account of his or her symptoms and what, if anything has been done to relieve the symptoms. d. Symptoms; the provider documents the patient's symptoms and diagnosis that correlate with those symptoms. - c. Subjective; patient's account of his or her symptoms and what, if anything has been done to relieve the symptoms. In evaluation and management services, what does the A stand for in SOAP? What is included in this section? a. Activity; documentation supports the patient's level of activity expected b. Assessment; the provider documents an assessment of the patient's condition. c. Action; action items the patient is to take to improve his or her conditions
