Chapter 5 — Quiz

Twenty-four questions. Nothing here is legal advice.

Multiple choice

1. Fraud differs from abuse principally in that fraud requires:

  • A. a federal payer
  • B. intent
  • C. more than one claim
  • D. an overpayment

2. "Knowingly" under the False Claims Act includes:

  • A. actual knowledge only
  • B. actual knowledge, deliberate ignorance, or reckless disregard
  • C. specific intent to defraud only
  • D. simple negligence

3. A private individual who files a False Claims Act suit on the government's behalf is a:

  • A. respondent
  • B. relator
  • C. contractor
  • D. intervenor

4. The Anti-Kickback Statute is:

  • A. civil and strict liability
  • B. criminal, requiring knowing and willful conduct
  • C. applicable only to physicians
  • D. limited to cash payments

5. The physician self-referral law (Stark) requires proof of:

  • A. intent to induce referrals
  • B. no intent — it is strict liability
  • C. an actual overpayment
  • D. patient harm

6. Protection under an Anti-Kickback safe harbor requires:

  • A. substantial compliance
  • B. satisfying every element
  • C. a written opinion from counsel
  • D. notification to the OIG

7. An identified overpayment from a federal health care program must be reported and returned within:

  • A. 30 days
  • B. 60 days
  • C. 90 days
  • D. 180 days

8. Exclusion prohibits federal program payment for items or services:

  • A. billed by the excluded person only
  • B. furnished, ordered, or prescribed by the excluded person, including where they are employed in any capacity by a billing provider
  • C. furnished in the excluding state
  • D. furnished after notice is published

9. Which is not one of the seven compliance program elements?

  • A. Written policies and standards of conduct
  • B. Effective lines of communication
  • C. Annual employee satisfaction surveys
  • D. Prompt response to detected offenses

10. The compliance element most likely to reduce qui tam exposure is:

  • A. written policies
  • B. effective lines of communication
  • C. training
  • D. disciplinary guidelines

11. The HIPAA rule that mandates ICD-10-CM, CPT, and HCPCS as national code sets is the:

  • A. Privacy Rule
  • B. Security Rule
  • C. Transactions and Code Sets Rule
  • D. Breach Notification Rule

12. The minimum necessary standard does not apply to disclosures for:

  • A. payment
  • B. treatment
  • C. health care operations
  • D. audits

13. A billing company that codes claims on behalf of a physician practice is a:

  • A. covered entity
  • B. business associate
  • C. clearinghouse in all cases
  • D. neither

14. Downcoding is best described as:

  • A. the conservative and safe approach
  • B. an inaccuracy that forfeits revenue, corrupts data, and is not a legal defense
  • C. permissible when documentation is unclear
  • D. required when a coder is uncertain

15. An internal audit identifies a systematic overcoding problem and the organization takes no action. The principal legal consequence is that subsequent identical claims:

  • A. are unaffected
  • B. may now satisfy the knowledge element
  • C. become criminal per se
  • D. are automatically extrapolated

Short answer

16. State the four things a claim to a federal health program certifies.

17. Give a coding example of "reckless disregard" involving no intent to deceive.

18. Name four forms of remuneration under the Anti-Kickback Statute that are not cash.

19. Why does §5.6 say element 7 is the one organizations fail? What is the consequence?

20. List five mundane HIPAA failures that occur in business offices.

21. (Chapter 4) A supervisor asks providers to supplement documentation after a records request arrives. Name the two distinct problems this creates.

22. Give the six-step sequence for responding to an instruction to code something the documentation does not support.

23. (Chapter 2) Explain why routinely waiving a Medicare beneficiary's coinsurance implicates the Anti-Kickback Statute, and name the compliant alternative.

24. Using Figure 5.1, explain why 11 of 42 claims that may have been legitimate could not be defended.

Answer key **1.** B. **2.** B. **3.** B. **4.** B. **5.** B. **6.** B — safe harbors are all-or-nothing. **7.** B. **8.** B. **9.** C. **10.** B — insiders bring qui tam cases, and they go outside when inside does not work. **11.** C. **12.** B. **13.** B. **14.** B. **15.** B. **16.** That the services were actually furnished; that they were medically necessary; that the information is true, accurate, and complete; and that the claim complies with applicable law, including the kickback and self-referral prohibitions. **17.** A modifier appended to every claim carrying a given code pair by a billing macro, with no human reading any operative note. Nobody decided to unbundle anything; the configuration did it at volume, and the absence of review is the recklessness. (Figure 5.1.) **18.** Free or below-market rent; subsidized staff or services; discounted or free equipment and supplies; meals, travel, or speaking fees; waived patient cost sharing. (Any four.) **19.** Because auditing (element 5) produces a report and is comparatively easy, while corrective action (element 7) requires changing how the organization works. **The consequence is that an unactioned audit finding establishes knowledge** — it converts every subsequent identical claim from an error into a knowing one, which is precisely the mechanism §5.2 describes. An organization that audits and does not correct has manufactured the evidence against itself. **20.** Sending the whole chart with an appeal when four pages were needed; faxing to a stale number; emailing PHI unencrypted under deadline pressure; discussing an account within earshot at a front desk; working from home on a shared device; and looking up a record with no business reason — curiosity, which is detected by audit log review and reliably ends employment. **21.** First, **timing becomes part of the record** — even a truthful, properly labeled addendum carries a date the reviewer will see, and documentation appearing after a request invites a harder look. Second, **if improperly labeled it is a false statement**, moving the organization from a payment problem to a potential fraud problem, and the audit trail will show it. **22.** (1) Make sure you are right. (2) Assume good faith and ask a question rather than accuse. (3) Put it in writing as a record. (4) Code what the documentation supports — not negotiable. (5) Escalate through the compliance channel. (6) If there is no channel or it does not work, seek advice outside the organization, including counsel. **23.** The waiver is remuneration to a beneficiary, capable of being characterized as an inducement to obtain services payable by a federal program; it can also constitute a false statement about the provider's actual charge and typically breaches the participation agreement's obligation to collect cost sharing. **The compliant alternative** is an individualized, documented financial hardship determination made under a written policy applied uniformly — the OIG's distinction is between a case-by-case documented finding and a routine or advertised waiver. **24.** Because the defense to an unbundling allegation is **contemporaneous documentation** that the debridement was separate and distinct — and the operative notes did not document it. The surgeons' later recollection that 11 were genuinely separate may well be true and is worth nothing evidentially, because the record does not distinguish those 11 from the other 31. **A defense cannot be built retroactively**, and building one after a records request creates a worse problem than the one it solves (Chapter 4 §4.5).