NCCT Review | Law and Ethics

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. A physician using self-referral. 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.

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.

A. Complete the insurance claim accurately. D. Submit claims to third party payer. E. Apply credit and collection laws.

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

A. Federal Civil False Claim Act The Federal Civil False Claim Act prohibits the submission of knowingly false claims for the purpose of receiving extra, undue, money.

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.

A. Follow current billing and coding practices. C. Ask for clarification when documentation does not support coding. D. Abstract data from the patient EHR Summary Page. 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.

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.

A. Patient consistently fails to keep appointments. B. Patient fails to make payment arrangements on a delinquent account. D. Patient is non-compliant with medical treatment.

An intentional tort in which unconsented, harmful, or unwarranted physical contact occurs is an example of A. battery. B. malpractice. C. abuse. D. negligence.

A. battery. 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.

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

A. child abuse B. gunshot wound E. abortion 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.

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

A. clearing house C. pharmacies D. nursing home facility

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."

B. "Waiving the copay would violate the anti-kickback law."

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.

B. Alert the insurance carriers.

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

B. Anti-Kickback Act

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.

B. Calling relatives to inquire about the debtor's contact information.

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

B. Fair Debt Collection Practices

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.

B. Fair Debt Collection Practices Act.

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

B. OIG

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)

B. Office of Inspector General (OIG)

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

B. Truth In Lending Act

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

B. Truth in Lending Act 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.

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.

B. You must identify yourself and the reason for your call. C. You may call between 8 am and 9 pm. E. You may not say they could be dismissed as a patient for non-payment.

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

C. EHR meaningful use. 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.

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

C. Stark Law

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

C. inadvertent coding errors 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.

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.

D. Call the guarantor to remind him of the balance due.

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

D. False Claims Act The practice of upcoding is a violation of Medicare laws and falls under the umbrella of the False Claims Act.

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

D. Federal False Claims Act The Federal False Claim Act prohibits the submission of knowingly false claims for the purpose of receiving extra, undue, money.

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

D. Stark Law 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.

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

D. Stop billing the claims and contact the facility's compliance officer

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.

D. fraud.

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.

D. the Anti-Kickback law. 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.

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.

D. the patient has signed an authorization form.