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Compliance, HIPAA & Medicare
Regulatory · Advanced · 1 lessons
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HIPAA, the False Claims Act & audit readiness
16 min read
Compliance programs rest on the minimum necessary standard, the False Claims Act, the Anti-Kickback Statute and Stark Law. Fraud requires knowing intent; abuse does not. The OIG's seven elements of an effective compliance program are the framework auditors expect.
- ✓Upcoding, unbundling and billing for services not rendered are classic False Claims Act exposures.
- ✓Medicare Part A inpatient · Part B outpatient/professional · Part C Advantage · Part D drugs.
- ✓OIG seven elements: standards/procedures, oversight, training, communication, auditing/monitoring, enforcement, corrective action.
- ✓Breach notification is required without unreasonable delay and no later than 60 days after discovery.
- ✓Retain documentation per payer and state requirements — commonly 7–10 years.
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Flashcards
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Case studies
Apply the guidelines to real documentation
Audit finding
An internal audit of 25 charts finds 4 office visits billed 99215 where documentation supports 99213, with no pattern of intent.
What is the appropriate response?
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Knowledge check
2 questions
1. Billing a higher-level E/M than documented is best described as:
2. Under HIPAA, breach notification to affected individuals must occur:
Verify all coding decisions against current official guidelines.