Government Audits and RACs Flashcards
7 cards from real CCT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Government Audits and RACs flashcards as text
Which federal law established the False Claims Act (FCA) liability for knowingly retaining Medicare overpayments beyond the 60-day repayment window?
Answer: Affordable Care Act (2010)
Section 6402 of the Affordable Care Act (2010) codified the 60-day overpayment return rule and tied failure to repay to False Claims Act liability.
During a RAC audit, a physician practice receives an ADR for records supporting E/M level 4 and 5 visits. What is the MOST likely reason for this request?
Answer: The practice has unusually high utilization of high-complexity E/M codes compared to peers
RACs use data analytics to flag providers who bill high-level E/M codes at rates that significantly exceed peer benchmarks, triggering record requests.
An Administrative Law Judge (ALJ) hearing is which level of the Medicare appeals process?
Answer: Level 3
An ALJ hearing is Level 3 of the five-level Medicare appeals process, following the MAC redetermination (Level 1) and QIC reconsideration (Level 2).
Which of the following scenarios would most likely trigger a UPIC fraud investigation rather than a standard RAC audit?
Answer: A DME supplier billed for equipment never delivered to beneficiaries
Billing for services or equipment never provided is a hallmark of fraud, which falls under UPIC (program integrity) jurisdiction rather than RAC payment accuracy review.
What does 'probe and educate' refer to in the context of MAC post-payment reviews?
Answer: A targeted small-scale review followed by provider education before full-scale audit action
Probe and educate is a MAC strategy of reviewing a small number of claims, providing education to the provider, and then re-reviewing to assess improvement before escalating.
A compliance officer learns that a competitor was audited for a specific billing practice. According to best compliance practices, the officer should:
Answer: Conduct an internal self-audit of the same billing practice in their own organization
External audit findings in the same specialty are a red flag to proactively self-audit the same practice, as CMS often expands audits across similar provider types.
Which best describes the role of a Compliance Technician when a RAC demand letter is received?
Answer: Coordinate record retrieval, evaluate the findings, and support the appeals decision
A Compliance Technician supports the organization's response by gathering documentation, assessing the audit finding, and helping leadership decide whether to repay or appeal.