CPCO chapter 10

The compliance program cannot be successful if employees answer "I don't know" to which of the following questions? Who is your compliance officer" "Who is your Medical Director" "Who is your third party billing company" "Who is your accountant"

"Who is your compliance officer" An investigator may ask employees, "Who is your compliance officer?" or "When did you have your last compliance training?" or "How do you make an anonymous report regarding compliance?" If the answer to any of these is "I don't know-or what are you talking about?" you probably will be in trouble.

Medical practices should be aware of risks identified in the past and then establish policies and procedures for what? Continual auditing Continual monitoring Continual training Continual reporting

Continual monitoring Monitoring focuses on the business processes and determinations of vulnerabilities. Monitoring looks at risk factors and thresholds that identify when a process or policy is out of compliance. Medical practices should be aware of risks identified in the past and then establish policies and procedures for continual monitoring.

The Compliance Officer for ABC Family Medical Group explains to the Board, which is made up of physician owners, that because it is considered the overarching criteria for determining a level of service, the provider must ensure that the documentation supports what? CPT® codes Diagnosis codes HCPCS codes Medical necessity

Medical necessity Each provider is personally and specifically responsible for properly documenting the services he or she provides. The provider must ensure that the documentation supports the medical necessity of the office visit, and use the appropriate procedure and diagnosis code.

PAR means what? Physicians agree to take assignment on all Medicare claims Physicians will not take assignment on all Medicare claims Physicians agree to take 100% on all Medicare claims Physicians agree to reassign payment on all Medicare claims

Physicians agree to take assignment on all Medicare claims PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount (Generally, Medicare pays 80% and the patient pays 20% in copayments) as payment in full for all covered services for the duration of the calendar year.

Which one of the following is Medicare used as a secondary payer? Medicare is never a secondary payer When one has both Medicare and Medicaid When workers' compensation is involved It does not make a difference if Medicare is primary or secondary because Medicare will pay its own share.

When workers' compensation is involved The following is when Medicare becomes a secondary payer: Workers' Compensation, Federal Black Lung benefits, and Veteran's Administration (VA) benefits. Medicare regulations require that all entities that bill Medicare for items or services rendered to beneficiaries must determine whether Medicare is the primary payer for those items or services. if an error is made and Medicare is billed as primary when the patient has primary coverage through another payer, refund Medicare and bill to the patient's primary insurance. After the primary insurance processes the claim, a secondary claim must be sent to Medicare.

After Carol, Compliance Officer for XYZ Internal Medial Group identifies a provider as an outlier or different vulnerabilities are identified with risk ratings, an important next step is to develop_________. an audit and corrective action plan an audit and disciplinary actions an audit and additional training training and corrective action plan

an audit and corrective action plan After a provider is identified as an outlier or different vulnerabilities are identified with risk ratings, it is important to develop an audit and corrective action plan.

Regulations state that services provided by teaching physicians in teaching settings are generally payable under the physician fee schedule only if the services are personally furnished by a physician who is ______. a resident. a fellow not the chief of staff not a resident

not a resident Regulations provide that services provided by teaching physicians in teaching settings are generally payable under the physician fee schedule only if the services are personally furnished by a physician who is not a resident or the services are furnished by a resident in the presence of a teaching physician or the teaching physician must be present during the key portion of any service or procedure for which payment is sought.

Medicare requires physicians and mid-level providers to certify the need for physical, occupational, and speech therapy. The first certification is needed within how many days of starting therapy? 10 20 30 60

30 Medicare requires that physicians and mid-level providers certify the need for physical, occupational, and speech therapy. The first certification is needed within 30 days of the patient starting therapy. After that, certifications are needed every 90 days. (Note: Some states may want recertification's every 30 days.)

Medicare requires that physicians or mid-level providers certify the need for physical, occupational, and speech therapy. The first certification is needed within how many days of the patient starting therapy? 10 20 30 45

30 Medicare requires that physicians or mid-level providers certify the need for physical, occupational, and speech therapy. The first certification is needed within 30 days of the patient starting therapy. After that, certifications are needed every 90 days (note: some states may want recertifications every 30 days).

The Patient Protection and Affordable Care Act (PPACA) enacted a civil monetary provision that requires the return of overpayments within how many days of identifying it? 30 45 60 90

60 The Patient Protection and Affordable Care Act (PPACA) enacted a civil monetary provision that requires the return of overpayments within 60 days of identifying an overpayment. Providers should not delay an investigation, but should take the time to thoroughly research an issue to determine if there is a problem.

Routine waiver of Medicare deductibles or copayments is a violation of which statute? Anti-Kickback Civil Monetary Penalties False Claims Act Stark II

Anti-Kickback Patient discounts that involve the provision of services at no charge, or the waiver of a patient's copayment or deductible, may raise concerns under the federal Anti-Kickback Statute (AKS). The OIG has stated that routine waivers of Part B service copayments for federal program beneficiaries may violate the AKS.

In certain cases, a provider, practitioner or supplier who accepts "insurance only" and routinely waives Medicare copayments or deductibles also could be held liable under what law? Anti-Kickback Statute False Claims Act Stark Law Qui Tam Provisions

Anti-Kickback Statute In certain cases, a provider, practitioner or supplier who routinely waives Medicare copayments or deductibles also could be held liable under the Medicare and Medicaid anti-kickback statute. 42 U.S.C.1320a-7b (b).

It is important to explain to the staff that retaliation between employees, such as stating, "I can get Suzie in trouble because she irritates me, and I want her fired" is considered what type of reporting? Bad faith reporting Good faith reporting HR reporting Disciplinary reporting

Bad faith reporting It is important to explain to the staff the difference between good faith reporting and bad faith reporting. Retaliation between employees "I can get Suzie in trouble because she irritates me, and I want her fired" would be bad faith reporting. Also, if the reporter is involved in the instance of non-compliance, there will be no retaliation for the reporting, but he/she will be disciplined in the appropriate manner for the non-compliance.

To avoid a conflict of interest, the OIG specifically states that the compliance officer should not report directly to whom? CFO CEO Board Members Providers

CFO The OIG's guidance specifically states that a CFO may not be a "good choice" as they may have a conflict with the duties necessary and their desire for fiscal efficiency. This is also why the compliance officer/committee reports to the "top," so there is no conflict of interest.

______is the practice of coding/charging one or two mid-level service codes exclusively, such as billing only E/M levels 99213 and 99214 regardless of the services performed for the established patient, based on the philosophy that the charges will average out over an extended period. In reality, this overcharges some patients while undercharging others. Up-coding Down coding Un-Bundling Clustering

Clustering This is the practice of coding/charging one or two mid-level service codes exclusively, such as billing only E/M levels 99213 and 99214 regardless of the services performed for the established patient, based on the philosophy that the charges will average out over an extended period. In reality, this overcharges some patients while undercharging others.

Steve, Director of Compliance for Small Rural Hospital Group, explains to the physicians that some of the most common reasons for claim denials in the current reimbursement environment are related to _______. CPT® codes Diagnosis Codes Modifiers HCPCS codes

Diagnosis Codes Some of the most common reasons for claims not being paid in the current reimbursement environment are related to the diagnosis. The basic requirement is that the diagnosis must justify the procedure performed and documented in the medical record. Diagnosis codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the complexity of the E/M services provided.

LCDs and NCDs provide information for coverage limited to certain what? CPT® codes Diagnosis codes HCPCS Level II codes Inpatient codes

Diagnosis codes LCDs and NCDs provide information for coverage limited to certain diagnoses. Coverage decisions may limit the frequency of an item or service, or deny an item or service outright as experimental and non-covered. Private payers may follow CMS' NCDs, or they may have their own LCDs.

Accountable care organizations (ACOs) involve different providers, including hospitals and physicians. Members of the ACO share both the gains and losses for certain Medicare fee-for-service beneficiaries with high-risk conditions such as heart failure, COPD, and diabetes. What is this arrangement called? Fair market value Gainsharing Tax exemption Compensation arrangemenent

Gainsharing PPACA had significant provisions to allow for gainsharing. Accountable care organizations (ACOs) involve different providers, including hospitals and physicians. Members of the ACO share both the gains and losses for certain Medicare fee-for-service beneficiaries with high-risk conditions such as heart failure, COPD, and diabetes.

After an audit reveals areas for improvement, what is the next step a Compliance Officer should take? Call a staff meeting Implement corrective action plans Schedule an investigation only Notify the board

Implement corrective action plans After an audit reveals areas for improvement, corrective action plans should be implemented.

Which Medicare services, require physicians to complete a Certificate of Medical Necessity (CMN)? Medicare covered durable medical equipment (DME) Medicare covered home health services (HH) Medicare covered long term care (LTC) Medicare covered outpatient services (OPS)

Medicare covered durable medical equipment (DME) Some services—in particular, Medicare covered durable medical equipment (DME)—require physicians to complete a Certificate of Medical Necessity (CMN). The CMN requirement is intended to curb abusive and fraudulent DME companies. There are specific requirements about which sections of the CMN form the physician must complete.

Under MSP, the Medicare statute and regulations require all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether_______________. Medicare is the primary payer for those items or services. Medicare considers the item or service covered according to a National Coverage Determination Workers' Compensation is the primary payer for those items or services. Medicaid is the primary payer for those items or services.

Medicare is the primary payer for those items or services. The MSP provisions apply to situations when Medicare is not the beneficiary's primary health insurance coverage. Medicare statute and regulations require all entities that bill Medicare for items or services rendered to beneficiaries must determine whether Medicare is the primary payer for those items or services.

Hannah is the Compliance Officer for Orange Hospital. She is explaining to her mother that Medicare Part B pays for what type of services? Hospice Inpatient Pharmacy Physician

Physician Medicare Part B pays for services that physicians provide to program beneficiaries.

Implementing an effective Compliance Program significantly reduces what Audits Incidents Regulations Risk

Risk Although implementing an effective Compliance Program may not eliminate all fraud, abuse and waste from a practice or organization, it does significantly reduce the risk of improper or even illegal conduct by all employees.

Modifier 25 is used to allow additional payment for E/M services performed by a provider on the same day as a procedure, as long as ____________. The E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are on the same day, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are minimal, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are significant, related to the last visit, and above and beyond the usual preoperative and postoperative care associated with the procedure.

The E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. Modifier 25 Significant, Separately Identifiable evaluation and management service by the same physician on the same day of the procedure or other service is used to allow additional payment for E/M services performed by a provider on the same day as a procedure, as long as the E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. Different diagnoses are not required. This modifier must not be used to report an E/M service that resulted in a decision for surgery.

To ensure that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting it is important to have what on the claim? The correct date The correct place of service The correct CPT codes The correct diagnosis

The correct place of service Physicians are required to identify the POS on the health insurance claim forms that they submit to Medicare contractors. The correct POS code ensures that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting.

Improper advertising can get the physician in trouble with whom? Attorney general CMS OIG The state licensing board

The state licensing board Improper advertising can get the physician in trouble with the state licensing board.

Dr. P is a family practice physician who hires a nurse practitioner (NP) to help with his patient load. The NP has her own NPI and is contracted with Medicare to provide services. The NP sees all new patients on Friday because Dr. P takes Fridays off. Who should the services to Medicare beneficiaries be billed under and why? The visits should be billed under Dr. P's NPI because the NP is an employee of Dr. P. The visits should be billed under Dr. P's NPI because the provider is only required to be available by phone to report incident-to services. The visits should be billed under the NP's NPI because supervision requirements are not met for incident-to billing. The visits should be billed under the NP's NPI because any services reported by the NP are not reportable under Dr. P, under any circumstance.

The visits should be billed under the NP's NPI because supervision requirements are not met for incident-to billing. The rules for incident-to billing are well documented. Incident-to can be defined as, "a Medicare billing method which allows services provided in an outpatient setting to be performed by auxiliary personnel and billed under the physician's national provider identification (NPI) number. The services or supplies that are furnished are an integral, although incidental, part of the physician's professional services and are provided in the course of diagnosis or treatment of an injury or illness." The sticking point is the supervision requirement. The services provided must be delivered under the physician's direct supervision. The physician must be in the area where care is delivered and immediately available to provide assistance and supervision. The physician must be the person to initiate a course of treatment and the service provided by the auxiliary staff is follow-up care in the capacity of assisting in providing the plan of care.

_________ is billing for a more expensive service than the one actually performed. In the hospital setting, ______ is in the form of using higher rated (paying) diagnostic related group (DRG) codes. The same can happen in surgical procedures, therapy services, radiology, and laboratory services. Code Creep Clustering Double Billing Up-Coding

Up-Coding Up-coding is billing for a more expensive service than the one actually performed. In the hospital setting, up-coding is in the form of using higher rated (paying) diagnostic related group (DRG) codes. The same can happen in surgical procedures, therapy services, radiology, and laboratory services.

Advanced Beneficiary Notices should be presented: To every patient, in case the service or procedure is not paid by Medicare. When an outpatient service is expected to be denied as not medically necessary. When outpatient service is not a covered benefit/service of Medicare. Never, as it may upset the patient.

When an outpatient service is expected to be denied as not medically necessary. Services that are never covered or are excluded from Medicare coverage do not require an ABN. Services that are covered but may be denied due to a non-covered diagnosis or frequency limitations are examples of when an ABN should be used.

An initial review of all areas of possible non-compliance within the practice/organization is necessary to reveal what areas of the practice/organization are currently in compliance with, and which areas they are not. This assessment is called what? baseline periodic auditing and monitoring incident tracking

baseline The compliance guidance issued by the OIG and previous chapters in this text have emphasized the need for identification, mitigation, and continued monitoring of risk within the medical practice/healthcare organization. There are various ways of accomplishing these tasks, but all start with determining the present status of the organization's risk. To go forward, the organization must know where they stand now to determine how to achieve a tolerable risk level. Risk will never be completely alleviated, but it can be minimized greatly.This process begins with a baseline audit of the organization's billing and reimbursement department, its current policies and procedures, and an analysis of staff members' understanding of the billing and reimbursement rules and regulations. This analysis is accompanied by the performance of audits.

Many times a Compliance Committee will review provider documentation on a regular basis. When a practice identifies that a provider is an outlier, it becomes most important to verify that the billed services are what? audited promptly documented and coded accurately submitted timely scrubbed prior to submission

documented and coded accurately If Medicare identifies a provider as an outlier it is not a forgone conclusion that the provider is submitting inappropriate claims, however, when a practice identifies that a provider is an outlier, it becomes prudent to verify that the billed services are both documented and coded accurately and appropriately.

Sarah, Compliance Officer for Apple Hospital, explains to the physicians on staff that _________ can occur when the same service is billed to Medicare and then billed to a private insurance company or to the patient. clustering waste abuse double billing

double billing Double billing can occur when the same service is billed to Medicare and then billed to a private insurance company or to the patient. The OIG guidance states, "Although duplicate billing can occur due to simple error, the knowing submission of duplicate claims—which is sometimes evidenced by systematic or repeated double billing—can create liability under criminal, civil, and/or administrative law."

John, Compliance Officer for ABC Medical Group told the Board that when conducting a risk assessment, coding and billing are considered to be what level of risk to an organization? low moderate high critical

high Coding and billing are considered high-risk areas that should be closely monitored to assure compliance with regulations and guidelines.

Once a vulnerability or risk has been identified it is important to determine the risk rating. This is determined by_______________. the history of occurrence and the severity of impact the likelihood or probability of occurrence and the severity of impact the possibility of occurrence and the severity of impact the rate of occurrence and the severity of impact

the likelihood or probability of occurrence and the severity of impact Once a vulnerability or risk has been identified it is important to determine the risk rating. This is determined by the likelihood or probability of occurrence and then the severity of impact if it does occur.

During the monthly new hire training, the Compliance Officer for Apple Hospital explains that, as an element of a billing and reimbursement, the compliance program is essential. Employees must be aware of the compliance issues and the applicable laws and regulations, especially those that pertain to what? HIPAA the medical record department their specific job descriptions OSHA

their specific job descriptions Training, as an element of a billing and reimbursement compliance program, is essential. If the employees of the practice/organization are not aware of the compliance issues and the applicable laws and regulations that pertain to their specific job descriptions, then the organization's billing and reimbursement compliance program will flounder.