WorksheetsCBCS Unit One: The Revenue Cycle and Regulatory Compliance
Total questions: 74
Worksheet time: 37mins
Which of the following is often photocopied during patient registration? Select all that apply:
Insurance Card
CMS-1500 Form
Chargemaster
Remittance Advice
Drivers License
A physician’s office develops a user-friendly process for staff members to report suspected billing fraud and abuse. Which recommended component of a compliance program does this example demonstrate?
A. Internal monitoring and auditing
B. Corrective Action
C. Open Lines of Communication
D. Risk Assessment
A healthcare provider identifies several overpayments during the self-disclosure process outlined in the OIG provider self-disclosure protocol. What must the provider do?
Review a random sample of 100 claims to estimate damages.
Report the findings to the OIG Fraud Hotline.
Review at least 10 claims per service to assess for other improper payments.
Return all overpayments to the government.
Audit at least five claims for each federal healthcare program.
_______ occurs when providers do not report all the services provided or code for services that are lower than the level of care that was given to the patient.
Undercoding
Upcoding
Bundling
Unbundling
HIPAA defines information such as patient names, addresses, dates of birth, IP addresses, and URLs as
Patient Identifiers
Medical Procedures
Insurance Codes
Clinical Diagnoses
Why should a patient’s insurance coverage be recorded as primary, secondary, and tertiary?
To submit claims in the order in which each plan should pay
To confirm the order in which the patient purchased the insurance
To confirm the patient’s identity
To prevent duplication of prescribed medications
_____ provide or pay for the cost of healthcare.
Health Plans
Hospitals
Pharmacies
Medical Devices
The HIPAA Privacy Rule’s focus is to make sure that _____ remains privacy and secure.
Protected Health Information
Healthcare Identifiers
Provider Information
Health Claims
How does undercoding differ from upcoding?
Undercoding does not report the full extent of services, whereas upcoding bills for more expensive services than those provided.
Undercoding leads to increased reimbursement, whereas upcoding results in loss of revenue.
Undercoding bills for services that never occurred, whereas upcoding bills for more complex services than those provided.
Undercoding is compliant with all laws and regulations, whereas upcoding is an illegal practice.
Which task is a recommended follow-up activity after an audit by a regulatory agency or contractor? Select all that apply:
Select a sample of electronic health records (EHRs) for the auditor.
Update the internal monitoring plan to track any issues identified in the audit report.
Identify weaknesses that contributed to problems uncovered by the audit.
Assign staff members to develop a corrective action plan.
Designate a lead who will work with the auditor.
The HIPAA ________ Transaction SetNational Identifier StandardSecurity Rule requires that providers and their business associates have policies and procedures in place to ensure confidentiality of protected health information (PHI).
Privacy Rule
Transaction Rule
Identifier Rule
Disclosure Rule
Which scenario is an example of a beneficiary inducement?
A pharmaceutical company offers a psychiatrist remuneration to prescribe certain medications to Medicare patients.
A physician refers Medicaid patients to an occupational therapy practice owned by a sibling.
A durable medical equipment supplier offers gift cards to physicians who order their wheelchairs for Medicare patients.
A physician waives copays to entice new Medicare patients to come to the practice.
The ______ prohibits certain individuals from participating in federal healthcare programs if they have committed Medicare or Medicaid fraud or other health-related criminal offenses.
D. Exclusion Statute
A. False Claims Act
B. Anti-Kickback Statute
C. Stark Law
Overcoding charges are considered noncompliant and can lead to _____
Audits
Promotions
Awards
Discounts
Which type of improper billing practice has occurred when the billing code reflects a more expensive medical procedure than the one provided?
Undercoding
Upcoding
Unbundling
Double Billing
Which of the following acts specifically prohibits harassment, misrepresentation, threats, and spread of false information?
Fair Debt Collection Practices Act
Health Insurance Portability and Accountability Act
Health Information Technology for Economic and Clinical Health Act
False Claims Act
What information is provided to the healthcare provider on an electronic remittance advice (ERA)? Select all that apply?
A. Date of Service
B. Amount paid for the Service
C. EDI Number
D. Amount charged by the Provider
E. Patients Name
Which contractor is responsible for functions previously held by the Zone Program Integrity Contractor (ZPIC) and the Medicaid Integrity Contractor (MIC)?
Comprehensive Error Rate Testing (CERT) Contractor
Supplemental Medical Review Contractor (SMRC)
Recovery Audit Contractor (RAC)
Unified Program Integrity Contractor (UPIC)
Which resource stores reports about acts of fraud and abuse committed by healthcare providers and suppliers?
National Practitioner Data Bank (NPDB)
Fraud Prevention System (FPS)
Health Care Fraud Prevention Partnership (HFPP)
OIG Compliance Program Guidance
Which of the following acts specifically prohibits harassment, misrepresentation, threats, and spread of false information?
False Claims Act
Fair Debt Collection Practices Act
Health Information Technology for Economic and Clinical Health Act
Health Insurance Portability and Accountability Act
When establishing a voluntary compliance program at a physician’s office, what does the Office of Inspector General (OIG) recommend regarding the implementation of compliance and practice standards?
Develop a written manual of all standards, policies, and procedures that is accessible to staff.
Avoid changing established compliance standards to maintain consistency and to minimize confusion.
Evaluate the effectiveness of practice standards as part of an internal monitoring and auditing program.
Periodically update clinical forms to facilitate accurate, complete documentation of care.
Develop billing and coding policies within the office rather than using a third-party billing company.
What is the first step of the revenue cycle?
Claim Submission
Patient Billing
Patient Registration
Insurance Verification
Which improper billing practice occurs when a coder fails to capture services provided to a patient?
Clustering
Undercoding
Upcoding
Unbundling
What does a clearinghouse scrub for when processing a medical claim? Select all that apply?
A. Healthcare provider information
B. Incorrect insurance plan number
C. Terminated insurance plans
D. Incorrect diagnosis coding
E. Incorrect spelling of a patient’s name
According to the HIPAA Privacy Rule, what principle requires providers to make reasonable efforts to limit information only to the intended purpose?
A. Implied Consent
B. Release of Information
C. Minimum Necessary
D. Implied Release
What is the reason for verifying patient insurance benefits prior to rendering services?
To confirm the patient’s identity
To prevent prescribing a medication that could cause an allergic reaction
To ensure the insurance will cover the scheduled service
To avoid duplicating a prescribed medication
Which situation at a restaurant is an analogy for unbundling in the healthcare industry?
Charging a customer for several entrées that they never received
Billing a customer for each item on the plate instead of the entrée price
Excluding some of the items that a customer had ordered
Charging a customer for a more expensive menu item than the one served
Which improper billing practice occurs when a coder fails to capture services provided to a patient?
Clustering
Undercoding
Upcoding
Unbundling
Which resource stores reports about acts of fraud and abuse committed by healthcare providers and suppliers?
Fraud Prevention System (FPS)
National Practitioner Data Bank (NPDB)
Health Care Fraud Prevention Partnership (HFPP)
OIG Compliance Program Guidance
Which type of improper billing practice has occurred when the billing code reflects a more expensive medical procedure than the one provided?
Double billing
Undercoding
Upcoding
Unbundling
Which of the following statements regarding the functions of the HHA Office of Inspector General (OIG) is FALSE? Select ALL that apply:
The OIG provides compliance program guidance to assist healthcare providers in establishing a mandatory compliance plan.
The OIG enforces the Exclusion Act and imposes civil monetary penalties for violations.
The OIG accepts tips and complaints about potential fraud and abuse, including anonymous reports.
The OIG provides compliance program guidance to assist healthcare providers in establishing a voluntary compliance program.
The OIG enforces the Exclusion Act but cannot impose civil monetary penalties for violations.
A physician’s office uses incorrect diagnostic codes that reflect a more severe health condition than the patient has. Which improper billing practice has occurred?
Upcoding
Unbundling
Downcoding
Balance billing
Which of the following statements regarding the Medicare Fraud Strike Force is TRUE? Select ALL that apply:
It is coordinated by the Health Resources and Services Administration (HRSA).
It uses data analytics and engages in interagency collaboration to identify, investigate, and shut down fraud schemes.
It is part of a joint initiative between the DOJ and HHS.
It refers credible allegations of fraud to CMS so that fraudulent payments can be suspended.
It serves as an online repository for reports of medical malpractice, fraud, and abuse.
The ___ prohibits certain individuals from participating in federal healthcare programs if they have committed Medicare or Medicaid fraud or other health-related criminal offenses.
Criminal Health Care Fraud Statute
Patient Access and Medicare Protection Act
Exclusion Statute
False Claims Act (FCA)
Which improper billing practice is sometimes a misguided attempt to avoid an audit?
Upcoding
Undercoding
Unbundling
Double Billing
The ___ is an analytics technology that runs algorithms to detect potential fraud and abuse in Medicare Fee-for-Service before payment.
Medicare Fraud Strike Force
Fraud Prevention System (FPS)
Program Integrity Command Center
National Practitioner Data Bank (NPDB)
A physician receiving cash and gifts from a rehabilitation center in exchange for the referral of Medicare and Medicaid patients is an example of a ___
Kickback
Reimbursement
Charity
Consultation
Which scenario is an example of a beneficiary inducement?
A healthcare provider offers free transportation to Medicare patients to encourage them to use their services.
A patient pays their medical bill in full at the time of service.
A hospital provides standard care to all patients regardless of insurance.
A clinic sends appointment reminders to all patients.
Which of the following is an example of a kickback?
A physician waives copays to entice new Medicare patients to come to the practice.
A physician refers Medicaid patients to an occupational therapy practice owned by a sibling.
A durable medical equipment supplier offers gift cards to physicians who order their wheelchairs for Medicare patients.
A pharmaceutical company offers a psychiatrist remuneration to prescribe certain medications to Medicare patients.
Which of the following tasks is a responsibility of federal agencies to prevent billing fraud and abuse? Select ALL that apply:
Performing data analyses to detect potential signs of billing fraud and abuse
Providing protections and incentives for whistleblowers who report wrongdoing
Conducting investigations into suspected cases of fraud, waste, and abuse
Offering education and resources to support accurate, compliant billing and coding
Enforcing regulations that protect the integrity of federal healthcare programs
How does undercoding differ from upcoding?
Undercoding is compliant with all laws and regulations, whereas upcoding is an illegal practice.
Undercoding leads to increased reimbursement, whereas upcoding results in loss of revenue.
Undercoding does not report the full extent of services, whereas upcoding bills for more expensive services than those provided.
Undercoding bills for services that never occurred, whereas upcoding bills for more complex services than those provided.
A healthcare provider identifies several overpayments during the self-disclosure process outlined in the OIG provider self-disclosure protocol. What must the provider do? Select all that apply:
Review at least 10 claims per service to assess for other improper payments.
Report the findings to the OIG Fraud Hotline.
Audit at least five claims for each federal healthcare program.
Return all overpayments to the government.
Review a random sample of 100 claims to estimate damages.
Which contractor is responsible for monitoring fraud, waste, and abuse involving Medicare Parts C and D benefits?
Investigations Medicare Drug Integrity Contractor (I-MEDIC)
Unified Program Integrity Contractor (UPIC)
Supplemental Medical Review Contractor (SMRC)
Medicare Administrative Contractor (MAC)
Which contractor calculates the Medicare Fee-for-Service (FFS) improper payment rate?
Medicare Administrative Contractor (MAC)
Supplemental Medical Review Contractor (SMRC)
Recovery Audit Contractor (RAC)
Comprehensive Error Rate Testing (CERT) Contractor
Which task is a recommended follow-up activity after an audit by a regulatory agency or contractor? Select all that apply:
Select a sample of electronic health records (EHRs) for the auditor.
Assign staff members to develop a corrective action plan.
Identify weaknesses that contributed to problems uncovered by the audit.
Update the internal monitoring plan to track any issues identified in the audit report.
Designate a lead who will work with the auditor.
Which of the following benefits is associated with implementing a voluntary compliance program at a physician’s practice? Select all that apply:
Fewer billing and coding errors
Improved patient care
Reduced risk of a government-initiated investigation or audit
More efficient payment of claims
Reduced need for internal auditing
Which law includes a requirement that healthcare providers develop a compliance program?
Stark Law
Affordable Care Act (ACA)
Improper Payments Elimination and Recovery Act of 2010
False Claims Act (FCA)
During a self-audit, what would a healthcare organization evaluate during a standards and procedures review? Select all that apply?
Information on coding practices
Mechanisms for reporting billing fraud and abuse
Accuracy of bills and medical records
Policy manuals
What is the purpose of a baseline audit in a compliance program?
To reduce the need for future internal monitoring and self-audits
To provide a benchmark for measuring compliance risks and activities
To allow healthcare providers to compare their billing practices with their peers
To allow for ongoing analysis of claims prior to submission to prevent improper payments
Which task is a function of the Medicare Administrative Contractor (MAC)? Select all that apply:
Processing Medicare claims for payment
Helping to coordinate medical reviews and investigations with other contractors
Enrolling providers and suppliers in the Medicare program
Investigating suspected fraud and abuse in the Medicare and Medicaid programs
Calculating the Medicare Fee-for-Service (FFS) improper payment rate
A physician wants to assess their billing practices in relation to other healthcare providers in their state. Which tool will help achieve this goal?
Baseline audit
OIG provider self-disclosure protocol
Comparative billing reports (CBR)
OIG compliance program guidance
Which responsibility is a function of the Center for Program Integrity (CPI) of the Centers for Medicare and Medicaid Services (CMS)? Select all that apply:
Establish a process for physicians to self-disclose potential incidents of billing fraud and abuse.
Reduce the burden on healthcare providers so they can focus on patient care.
Offer education and outreach to improve compliance with laws, regulations, and program requirements.
Coordinate medical reviews and audits to prevent and address improper payments.
Provide guidance for developing a compliance program that is tailored to each sector of the healthcare industry.
When establishing a voluntary compliance program at a physician’s office, the Office of Inspector General (OIG) recommends which of the following regarding the implementation of compliance and practice standards?
Develop written standards and procedures to ensure compliance.
Rely solely on verbal instructions for compliance.
Ignore compliance standards unless required by law.
Implement compliance standards only after an audit.
The HIPAA Privacy Rule’s focus is to make sure that ___ remains privacy and secure.
Health claims
Provider information
Protected health information
Healthcare identifiers
The HITECH Act requires covered entities to notify individuals and ___ when there is a security breach of protected health information.
HIPAA Security Officer
Freedom of Information Committee
Ethics Committee
Health and Human Services
The HIPAA Security Rule requires that providers maintain standards to protect PHI from ___ access.
Patient
Provider
Unauthorized
Authorized
According to the HIPAA Privacy Rule, what principle requires a provider to make reasonable efforts to limit information only to the intended purpose?
Release of information
Implied consent
Implied release
Minimum necessary
Which of the following acts was established to improve healthcare quality, safety, and efficiency using health information technology?
False claims act
Fair debt collection practices act
Health insurance portability and accountability act
Health information technology for economic and clinical health act
Which of the following code sets are required by the HIPAA Transaction and Code Set standard? Select ALL that apply:
International Classification of Diseases (ICD-10-PCS)
Healthcare Common Procedure Coding System
International Classification of Diseases (ICD-10-CM)
12. ____ process claims between providers and payers.
Healthcare Clearinghouses
Medical Laboratories
Pharmaceutical Companies
Insurance Agents
The ___ prohibits a provider from referring patients to a facility where the provider has a financial interest.
Stark Law
HIPAA
False Claims Act
Anti-Kickback Statute
Which of the following acts contains four standards used to keep health information private and secure?
False Claims Act
Health Insurance and Accountability Act (HIPAA)
Fair Debt Collection Practices Act
Health Information Technology for Economic and Clinical Health (HITECH) Act
Which of the following acts specifically prohibits harassment, misrepresentation, threats, and spread of false information?
Health Information Technology for Economic and Clinical Health Act
Fair Debt Collection Practices Act
False Claims Act
Health Insurance Portability and Accountability Act
What is the reason for verifying patient insurance benefits prior to rendering service?
To ensure the insurance will cover the scheduled service
To avoid duplicating a prescribed medication
To confirm the patients identity
To prevent prescribing a medication that could cause an allergic reaction
What information is provided to the healthcare provider on an electronic remittance advice (ERA)? Select ALL that apply:
Patients name
EDI number
Amount charged by the provider
Amount paid for the service
Date of service
Which action should a medical biller take when a claim has not been paid within 30 to 45 days?
Contact the patient
Resubmit the claim
Contact the insurance plan
Notify the healthcare provider
Which of the following is often photocopied during patient registration? Select ALL that apply:
Insurance card
Remittance advice
CMS-1500
Drivers License
Chargemaster
What does the clearinghouse scrub for when processing a medical claim? Select ALL that apply:
Incorrect insurance plan number
Terminated insurance plans
Healthcare provider information
Incorrect spelling of a patient's name
Incorrect diagnosis coding
If an account is placed in collections, the balance is written off as a ____.
Bad Debt
Asset
Revenue
Prepaid Expense
When paper claims are submitted, what is sent to the health insurance payer?
A completed claim form
A payment receipt
A prescription
A patient ID card
Fill in the blank: The ______ is a unique identifier used for electronic data interchange in healthcare.
EDI Number
Patient ID
Medical Record Number
Provider License Number
Fill in the blank: The ______ is a standard form used for submitting medical claims to insurance companies.
CMS-1500 claim form
UB-04 form
HCFA-1450 form
ADA Dental Claim form
Fill in the blank: The ______ outlines the financial policies and procedures for patients in a healthcare facility.
Financial policy form
Patient consent form
Medical history form
Insurance claim form
Fill in the blank: ______ refers to the collection of personal and statistical information about a patient.
Demographic information
Medical history
Diagnosis
Treatment plan
