CCT Government Audits and RACs 3 — Questions and Answers
Question 1: The Comprehensive Error Rate Testing (CERT) program is designed to measure which of the following?
- Fraud rates in Medicare Advantage plans
- The Medicare fee-for-service improper payment rate (Correct answer)
- Medicaid underpayment rates by state
- RAC contractor performance accuracy
Correct answer: The Medicare fee-for-service improper payment rate
CERT measures the Medicare fee-for-service improper payment rate by reviewing a random sample of paid claims each year.
Question 2: A Zone Program Integrity Contractor (ZPIC) differs from a RAC primarily because ZPICs focus on:
- Underpayment recovery
- Fraud investigations and law enforcement referrals (Correct answer)
- Coding accuracy and DRG validation
- Hospital cost report reconciliation
Correct answer: Fraud investigations and law enforcement referrals
ZPICs (now largely succeeded by UPICs) are focused on investigating suspected fraud and can refer cases to law enforcement, unlike RACs which focus on payment accuracy.
Question 3: Which of the following best describes an 'automated review' conducted by a RAC?
- A review triggered by a whistleblower complaint
- A claim review based solely on data analysis without requesting medical records (Correct answer)
- A review conducted using statistical sampling and extrapolation
- A review initiated after a provider self-discloses an error
Correct answer: A claim review based solely on data analysis without requesting medical records
Automated reviews use claims data and logic edits to identify clear payment errors without requiring the provider to submit medical records.
Question 4: Under the RAC program, how are RAC contractors typically compensated?
- Fixed annual government contract fee
- Per-claim flat fee for every claim reviewed
- Contingency fee based on improper payments identified (Correct answer)
- Hourly rate for clinical reviewers
Correct answer: Contingency fee based on improper payments identified
RACs are paid on a contingency fee basis, receiving a percentage of the overpayments collected and underpayments identified.
Question 5: A provider receives a RAC Additional Documentation Request (ADR). What is the maximum number of medical records a RAC can request from a single provider within a 45-day period?
- 100 records
- 200 records
- No limit, at RAC's discretion
- Varies by provider type and size (Correct answer)
Correct answer: Varies by provider type and size
CMS establishes ADR limits based on provider type and claim volume to prevent administrative burden, and these limits vary accordingly.
Question 6: Which Medicare administrative appeals level involves review by a Qualified Independent Contractor (QIC)?
- Level 1 – Redetermination
- Level 2 – Reconsideration (Correct answer)
- Level 3 – ALJ Hearing
- Level 4 – Medicare Appeals Council
Correct answer: Level 2 – Reconsideration
Level 2 reconsideration is performed by a Qualified Independent Contractor (QIC), which is independent of the MAC that handled the Level 1 redetermination.
Question 7: During a government audit, a hospital discovers that it self-overpaid a Medicare cost report. Under the 60-day rule, the hospital must:
- Report and return the overpayment within 60 days of identification (Correct answer)
- Notify the OIG within 30 days but may repay over 12 months
- Wait for the MAC to issue a demand before repaying
- File an amended cost report within the fiscal year
Correct answer: Report and return the overpayment within 60 days of identification
The 60-day rule (ACA Section 6402) requires providers to report and return identified Medicare/Medicaid overpayments within 60 days of identification or face False Claims Act liability.
CCT Government Audits and RACs 3
The Comprehensive Error Rate Testing (CERT) program is designed to measure which of the following?