Compliance, Fraud and Abuse, and Payer Regulations
The rules that govern billing
Compliance in revenue cycle means following federal and state laws and payer rules. Candidates must understand the False Claims Act, Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law, and HIPAA. They must also know the elements of an effective compliance program and the role of the Office of Inspector General (OIG).
Concepts to master
- False Claims Act: knowingly submitting false claims; whistleblower provisions.
- Anti-Kickback Statute: remuneration for referrals of federally payable items.
- Stark Law: physician self-referral for designated health services.
- HIPAA privacy and security rules.
- Compliance program elements: policies, training, auditing, hotline, enforcement.
Traps in questions
A frequent trap is confusing the Anti-Kickback Statute (intent-based, covers all payers in some contexts) with Stark (strict liability, Medicare/Medicaid designated health services). Another is assuming a compliance program eliminates risk; it mitigates risk. Questions may also test whether a billing error is fraud; fraud requires intent, while errors are usually corrected.
Rule of thumb
Document, code, and bill what is true; if it feels like it is designed to increase referrals or payments improperly, it likely violates a rule.
Worked example
A physician refers patients to a lab in which the physician has a financial interest and the lab bills Medicare. This implicates Stark unless an exception applies. The analysis focuses on the financial relationship and the designated health service, not on intent.