Regulatory and Payer Compliance Requirements
What this domain tests
You must know the rules that govern who pays and under what conditions. Concepts: Medicare Conditions of Participation and coverage rules; the False Claims Act and its knowledge standard; Anti-Kickback Statute (intent-based, remuneration for referrals) vs. Stark Law (strict liability, designated health services, exceptions); the Physician Self-Referral framework; payer-specific requirements (prior authorization, medical policy, timely filing); HIPAA's Privacy and Security Rules as they affect review; and the Compliance Program elements (written standards, compliance officer, training, monitoring, reporting, enforcement, corrective action).
Traps that show up in questions
- Treating Stark and Anti-Kickback as interchangeable - Stark is strict liability and limited to DHS; AKS is intent-based and broad.
- Assuming 'the payer approved it' means it was compliant - payer approval does not cure a legal violation.
- Forgetting that prior authorization does not guarantee payment; medical necessity is still reviewed.
- Missing that a compliance program must have enforcement and corrective action, not just a policy binder.
- Overlooking that HIPAA permits review/audit uses under minimum-necessary and treatment/payment/operations exceptions.
Rule of thumb
Ask two questions: (1) Is it legal? (Stark/AKS/FCA) and (2) Is it payable? (coverage/medical policy). A 'yes' to one does not imply a 'yes' to the other.
Worked example
A hospital leases office space from a referring physician at above-market rent. Even if the payer approves the claims, the arrangement may violate the AKS (remuneration for referrals) and Stark (if DHS) unless a specific exception applies. The reviewer flags it for compliance/legal, not for coding.