NCCT REVIEW LAW AND ETHICS
23. A patient calls the physician's office and indicates that the provider is a friend of a friend who referred her and wants the provider to waive the routine office visit copay of $30. Which of the following statements should the insurance and coding specialist use in response? A. "We will waive the copay per the physician's instructions." B. "Waiving the copay would violate the anti-kickback law." C. "The practice attorney will review this situation and contact you." D. "I will need approval from the manager."
"Waiving the copay would violate the anti-kickback law." Rationale The Federal Anti-Kickback law is a statute that prohibits the exchange or offer to exchange, anything of value, in an effort to induce or reward the referral of federal health care program business. In this case the patient would be receiving her services at a discounted price simply because her friend is a friend of the provider.
3. Which of the following is an example of a Stark Law violation? A. A physician using self-referral. B. Unbundling procedures. C. Asking for payment from a minor. D. A physician receiving kickbacks.
A physician using self-referral. Rationale Stark Law is a set of federal laws that prohibits physician self-referral, specifically a referral by a physician of a government insurance patient to an entity providing health services if the physician (or an immediate family member) has a financial relationship with that entity.
29. A physician does not require his patients to pay copays. The insurance and coding specialist has told the physician this is an illegal practice. The physician continues to waive the copays. Which of the following indicates the appropriate course of action for the insurance and coding specialist? A. Ignore the situation because the physician owns the practice. B. Alert the insurance carriers. C. Add the copay amount to the patients' bills. D. Send written notices to the patients.
Alert the insurance carriers. Rationale Some states may be stricter than others when it comes to the practice of waiving copays and some may have harsher penalties, but it still a poor practice and not accepted by insurance carriers. If a physician is participating in unacceptable practices against an insurance carrier, that insurance carrier should be notified.
9. A local laboratory sent a physician two tickets to the football game, as a thank you for referring patients to its testing center. Which of the following has been violated? A. False Claim Act B. Anti-Kickback Act C. HIPAA D. Fraud and Abuse Act
Anti-Kickback Act Rationale According to the Anti-Kickback Act, it is illegal for a physician to accept money or gifts, such as football tickets, for referring patients. This type of practice lessens the integrity of the services provided. Patients may be referred simply so that the physician receives a gift.
13. Which of the following does the Fair Debt Collection Practice Act allow when contacting a guarantor about an outstanding bill? A. Send a post card confirmation of the agreement. B. Contact the guarantor's employer regarding wage garnishment. C. Leave a detailed message on the guarantor's voicemail regarding the debt. D. Call the guarantor to remind him of the balance due.
Call the guarantor to remind him of the balance due. Rationale A post card is not an acceptable way for a collector to contact a guarantor. A post card can be read by anyone, when this information should be protected. A collector can also not contact a person's employer to arrange for wage garnishments. Again, the person's health and debt information must be protected and the employer is not an entity entitled to that type of information. A detailed message cannot be left for the same reason. The message can be heard by anyone who has access to the message. A collector can call the guarantor to remind them of their balances, as long as it is confirmed that they are speaking with the correct person.
11. The HITECH Act was created to promote the use of A. better physician documentation. B. electronic claims submissions. C. EHR meaningful use. D. written consent for medical procedures.
EHR meaningful use. Rationale The HITECH ACT was created to promote the use of EHR meaningful use. The HITECH ACT improves the quality of patient care by making medical records easily accessible by all physicians in a practice.
22. The physician that the insurance and coding specialist works for is fraudulently billing for services that were not performed. The specialist has previously tried to talk to him about this, but he continues with these practices. Which of the following should the specialist contact? A. AMA B. OIG C. The Joint Commission D. NCQA
OIG Rationale The Office of Inspector General, which is part of the Department of Health and Human Services, has been given the power to enforce federal, state, and local laws to control healthcare fraud and abuse and to conduct investigations and audits.
18. Which of the following should the insurance and coding specialist do first when she suspects illegal practices under the Federal Civil False Claims Act? A. Continue to bill the claims and look for another job immediately. B. Correct the claim codes and submit the claims to OIG once updated. C. Make copies of the claims to use as evidence and contact the insurance carrier. D. Stop billing the claims and contact the facility's compliance officer
Stop billing the claims and contact the facility's compliance officer Rationale If the coding specialist suspects or questions the legalities of an office practice, he/she should always stop and ask the compliance officer. This could be a misunderstanding or a simply an error that can be rectified easily.
16. Which of the following laws requires full written disclosure about the finance charges for large payment plans involving four or more installments, excluding a down payment? A. Fair Debt Collections Practice B. Truth In Lending Act C. Equal Credit Opportunity Act D. Fair Credit Billing Act
Truth In Lending Act Rationale The Truth in Lending Act requires full disclosure about all finance charges and the timeline in which the debt is expected to be paid. There should be no undisclosed fees.
14. Which of the following requires that a medical practice informs the patients in advance interest will be charged on delinquent accounts? A. Stark Law B. Truth in Lending Act C. Fair Debt Collection Practices Act D. Omnibus Act
Truth in Lending Act Rationale The federal Truth in Lending Act requires that the patients are informed in advance, when the treatment is provided, if interest will be charged on a delinquent account. This applies to the collection of any amount (including any interest, fee, charge, or expense incidental to the principal obligation) unless such amount is expressly authorized by the agreement creating the debt or permitted by law.
1. Which of the following activities is an example of abuse rather than fraud? A. upcoding B. misrepresenting the diagnosis C. inadvertent coding errors D. billing for services not rendered
inadvertent coding errors Rationale Abuse is an unintentional mistake. Fraud is an intentional misrepresentation for gain. Upcoding, misrepresenting the diagnosis, and billing for services not rendered are examples of fraud. Inadvertent coding errors are examples of abuse.
4. A specialist gives a general practitioner concert tickets every time he refers a patient to him. This is illegal according to A. anti-trust law. B. HIPAA. C. the Stark law. D. the Anti-Kickback law.
the Anti-Kickback law. Rationale The Anti-Kickback law prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals. This includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.
10. A lawyer has called and demanded information about a patient in the office. The insurance and coding specialist can share the information if A. she calls the patient and obtains permission. B. the lawyer tells her that he has permission from the patient. C. the lawyer provides his identification number. D. the patient has signed an authorization form.
the patient has signed an authorization form. Rationale For the release of any medical information, the patient must have completed and signed a release of information consent. A call to the patient is not adequate. The consent must be in writing.
19. Which of the following collection activities is prohibited by the Fair Debt Collection Practices Act (FDCPA)? A. Calling the debtor during normal business hours. B. Calling relatives to inquire about the debtor's contact information. C. Providing the name of the creditor to whom the debt is owed. D. Contact the debtor by mail.
Calling relatives to inquire about the debtor's contact information. Rationale When collecting a debt, it is not permissible to call a person's relatives to inquire about the person's contact information. It is never acceptable to contact anyone except the person who owes the debt.
24. Which of the following are considered standard responsibilities for an insurance and coding specialist? (Select the three (3) correct answers.) A. Complete the insurance claim accurately. B. Waive copayments and coinsurance as required for patients. C. Transcribe medical records for physician. D. Submit claims to third party payer. E. Apply credit and collection laws.
Complete the insurance claim accurately. Submit claims to third party payer. Apply credit and collection laws. Rationale Insurance and coding specialists are not allowed to waive copayments and coinsurances and are also not allowed to transcribe on behalf of the physician. Both of these practices are illegal. Some standard responsibilities of the insurance and coding specialist are to complete claims accurately and timely, and to submit claims to the third party payer. They are also expected to know the rules of coding and be able to apply to appropriate codes and modifiers. They should also know the laws based on credit and collection and should be able to apply these laws to their daily tasks.
15. The insurance and coding specialist called the patient at 7:30 AM to discuss an outstanding balance. Which of the following acts did the specialist violate? A. Truth in Lending B. Fair Debt Collection Practices C. Fair Credit Billing D. Equal Credit Opportunity
Fair Debt Collection Practices Rationale Phone calls at any unusual time or place or a time or place known to be inconvenient to the consumer are not allowed. Calls are not allowed until after 8 o'clock am and not after 9 o'clock pm, local time at the consumer's location.
17. The insurance and coding specialist arrives at work at 6:00 am. One of the duties today is to follow up on patient delinquent accounts. The specialist knows that calls cannot start for the accounts until 8:00 am due to the A. Fair Credit Billing Act. B. Fair Debt Collection Practices Act. C. Truth in Lending Act. D. Fair Credit Reporting Act.
Fair Debt Collection Practices Act. Rationale The Fair Debt Collection Practices Act prohibits unfair collecting practices. This includes calling a debtor at unreasonable hours or on weekends, calling their employers, or threatening to revoke treatments.
5. During an annual audit, it is discovered that the office coding staff have up-coded procedures. Which of the following laws applies? A. Anti-kickback Law B. Stark Law C. HIPAA D. False Claims Act
False Claims Act Rationale The practice of upcoding is a violation of Medicare laws and falls under the umbrella of the False Claims Act.
6. Which of the following laws pertains to an insurance and coding specialist who knowingly presents an incorrect CMS 1500 for payment to a payer? A. Federal Civil False Claim Act B. OMNIBUS Act C. Stark Law D. Administrative Law
Federal Civil False Claim Act Rationale The Federal Civil False Claim Act prohibits the submission of knowingly false claims for the purpose of receiving extra, undue, money.
7. Which of the following regulates health care billing for services that are not medically necessary? A. Stark Law B. Patient's Bill of Rights C. Health Insurance Portability and Accountability Act D. Federal False Claims Act
Federal False Claims Act Rationale The Federal False Claim Act prohibits the submission of knowingly false claims for the purpose of receiving extra, undue, money.
26. Which of the following actions will help to protect an insurance and coding specialist from being charged with fraudulent behavior? (Select the three (3) correct answers.) A. Follow current billing and coding practices. B. Report only the codes that the provider selects. C. Ask for clarification when documentation does not support coding. D. Abstract data from the patient EHR Summary Page. E. Fill out the CMS-1500 completely.
Follow current billing and coding practices. Ask for clarification when documentation does not support coding. Abstract data from the patient EHR Summary Page. Rationale It is important for a billing and coding specialist to avoid committing fraud. One way to avoid committing fraud is by following current billing and coding practices. This means conscientiously educating themselves through seminars, articles, and using current materials and coding updates. They should also ask for clarification when documentation does not support coding. They should only code what is documented and should never code only what the physician selects. A billing and coding specialist should also be able to abstract data from the correct parts of the EHR summary page. Filling out a CMS-1500 form completely will not help to protect a billing and coding specialist because not every space needs to be filled out on every claim. It is important to be aware of what information is needed on specific claims.
21. If the insurance and coding specialist suspects major insurance fraud, which of the following should she report it to? A. World Health Organization (WHO) B. Office of Inspector General (OIG) C. Federal Bureau of Investigation (FBI) D. The Joint Commission (TJC)
Office of Inspector General (OIG) Rationale If an insurance and coding specialist suspects major insurance fraud, the Office of the Inspector General should be notified.
30. Which of the following are legitimate reasons for a provider to terminate a patient relationship? (Select the three (3) correct answers.) A. Patient consistently fails to keep appointments. B. Patient fails to make payment arrangements on a delinquent account. C. Patient is related to a staff member. D. Patient is non-compliant with medical treatment. E. Patient is disruptive in the waiting room.
Patient consistently fails to keep appointments. Patient fails to make payment arrangements on a delinquent account. Patient is non-compliant with medical treatment. Rationale The patient/physician relationship may be terminated by the physician if the patient misses too many appointments, if the patient does not make payments as scheduled, or is non-compliant with their medical treatment plan. For a physician to terminate a relationship with a patient, a written letter must be sent to the patient, clearly documenting the reasons why and giving them the names of some other physicians who may be able to treat them in the future. The letter must also contain a termination date, in the future, so that the patient has some time to find a new physician.
8. Which of the following regulations prohibits a physician from referring a patient to a facility in which the physician holds a financial interest? A. HIPAA B. Federal False Claims Act C. Stark Law D. Affordable Care Act
Stark Law Rationale Stark Law prohibits a physician from referring a patient to a facility in which the physician holds a financial interest. This law was written so that physicians do not take advantage of a patient's health situation. It is to deter physicians from lying to make extra money.
2. Which of the following legislation prohibits physicians from referring patients to an entity if the physician or a member of her immediate family has a financial relationship with the entity? A. Anti-kickback Statute B. Federal False Claims Act C. Exclusion Statute D. Stark Law
Stark Law Rationale Stark Law prohibits physicians from referring patients to an entity if the physician or immediate family member has a financial relationship with the entity so that a physician doesn't do referrals for personal gain. The Anti-Kickback Statute prohibits the physician from accepting gifts from an entity for referring patients. The Federal False Claims Acts states that it is illegal to make a false medical record or to file a false medical claim. The Exclusion Statue states certain circumstances in which entities can be banned from Medicare.
20. The insurance and coding specialist is training a new employee on collection procedures. Which of the following should she tell the new employee? (Select the three (3) correct answers.) A. You may leave a message at the patient's place of employment. B. You must identify yourself and the reason for your call. C. You may call between 8 am and 9 pm. D. You may call during the work week, but not on the weekend. E. You may not say they could be dismissed as a patient for non-payment.
You must identify yourself and the reason for your call., You may call between 8 am and 9 pm., You may not say they could be dismissed as a patient for non-payment. Rationale When attempting to collect a debt from a patient, there are laws that must be followed. After confirming the identity of the person, identify yourself and the reason for the call. Calls may be made between the hours of 8am and 9pm, during the work week, but not on weekends. It can be considered harassment if calls are made outside of that time period. Threatening to dismiss the patient for non-payment is not allowed. There is a specific protocol that must be followed to terminate a patient-physician relationship. A message cannot be left at a person's place of employment.
28. An intentional tort in which unconsented, harmful, or unwarranted physical contact occurs is an example of A. battery. B. malpractice. C. abuse. D. negligence.
battery. Rationale Battery is unwanted physical contact. Malpractice is illegal professional treatment. Abuse is the misuse of something, such as alcohol or power. Negligence is failure to provide proper care.
25. Which of the following are exceptions to the confidentiality requirement under HIPAA? (Select the three (3) correct answers.) A. child abuse B. gunshot wound C. overdose D. tuberculosis E. abortion
child abuse, gunshot wound, abortion Rationale HIPAA is an act that is in place to protect a patient's privacy. There are some situations that are exempt from that confidentiality, such as child abuse, elder abuse, gunshot wounds, and abortions (when required from a court). Abuse must be reported when suspected to protect the patient's well-being.
12. Which of the following meets the definition of a covered entity that must comply with HIPAA? (Select the three (3) correct answers.) A. clearing house B. employer C. pharmacies D. nursing home facility E. the patient
clearing house, pharmacies, nursing home facility Rationale HIPAA is enforced to protect the privacy of patients in the healthcare setting. It does not reach to the patient's employer. It does, however, cover any clearinghouses, pharmacies, nursing home facilities, physician offices, and insurance companies.
27. A clinical laboratory receives orders from a physician for a specific clinical laboratory test. The lab performs and bills for the tests indicated on the order, but also bills for additional tests that were not ordered or rendered. This illegal practice is considered A. kickbacks. B. malpractice. C. upcoding. D. fraud.
fraud. Rationale Submitting a claim or claims for a medical item or service that is not performed or medically necessary constitutes fraud.