ACMPE Quality Improvement and Compliance Flashcards

Which federal law governs the submission of false claims to Medicare and Medicaid and exposes violators to significant civil penalties?

Answer: False Claims Act

The False Claims Act imposes civil liability on individuals and organizations that knowingly submit fraudulent claims to federal healthcare programs.

In a medical practice, a root cause analysis (RCA) is primarily used to investigate which type of event?

Answer: Sentinel events or serious adverse outcomes

RCA is a structured process used to identify the underlying system failures that contribute to sentinel events and serious adverse patient outcomes.

Which quality indicator measures the proportion of patients who receive a recommended preventive service or treatment per established clinical guidelines?

Answer: Process measure

Process measures assess whether recommended clinical actions (e.g., screenings, vaccinations) are delivered to eligible patients.

Under OSHA's Bloodborne Pathogens Standard, medical practices must offer which vaccine to employees with occupational exposure risk at no cost?

Answer: Hepatitis B vaccine

OSHA requires employers to offer the hepatitis B vaccine series at no cost to employees with occupational exposure to bloodborne pathogens.

Which CMS quality payment program rewards eligible clinicians based on performance in quality, cost, improvement activities, and promoting interoperability?

Answer: Merit-Based Incentive Payment System (MIPS)

MIPS consolidates prior CMS quality reporting programs and adjusts Medicare payments based on composite performance scores.

A medical practice's compliance officer discovers a pattern of upcoding on claims. Which is the most appropriate immediate action?

Answer: Conduct an internal audit, quantify the overpayments, and voluntarily disclose to CMS

Voluntary disclosure through the OIG's Self-Disclosure Protocol allows practices to report and resolve overpayments, typically at reduced penalties.