CCT Government Audits and RACs 4 — Questions and Answers
Question 1: A Unified Program Integrity Contractor (UPIC) was created to replace which two legacy contractor types?
- RACs and MACs
- ZPICs and MICs
- CERTs and PSCs
- ZPICs and PSCs (Correct answer)
Correct answer: ZPICs and PSCs
UPICs consolidated the functions of Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) into a single contractor.
Question 2: What is the primary purpose of the OIG Work Plan in the context of government audits?
- To list providers currently under investigation
- To announce planned audits, reviews, and studies for the coming fiscal year (Correct answer)
- To publish final settlement amounts for resolved audits
- To set annual RAC contingency fee rates
Correct answer: To announce planned audits, reviews, and studies for the coming fiscal year
The OIG Work Plan outlines the audits, evaluations, and inspections the OIG intends to conduct, allowing compliance officers to proactively assess risk areas.
Question 3: Statistical sampling and extrapolation in a Medicare audit means that:
- Every claim in a date range is individually reviewed
- Findings from a sample are projected across all similar unpaid claims
- Only claims above $10,000 are subject to review
- Findings from a reviewed sample are projected to estimate overpayments across the universe of similar claims (Correct answer)
Correct answer: Findings from a reviewed sample are projected to estimate overpayments across the universe of similar claims
Extrapolation applies an error rate found in a statistical sample to the entire universe of similar claims, potentially resulting in large overpayment demands from a small sample.
Question 4: Under which condition may a Medicare contractor NOT use extrapolation to expand overpayment findings?
- When the provider is a critical access hospital
- When there is no sustained or high level of payment error and no prior education attempts (Correct answer)
- When the audit covers fewer than 3 years of claims
- When the provider has not yet responded to an ADR
Correct answer: When there is no sustained or high level of payment error and no prior education attempts
CMS policy limits the use of extrapolation to situations involving a sustained or high level of payment error or where education has failed to correct billing problems.
Question 5: Which of the following is a key difference between a MAC post-payment review and a RAC audit?
- MACs can only review inpatient claims; RACs review all claim types
- MACs identify both fraud and billing errors; RACs only identify fraud
- RACs are paid on contingency; MACs are paid a flat administrative fee (Correct answer)
- RACs focus on underpayments only; MACs focus on overpayments only
Correct answer: RACs are paid on contingency; MACs are paid a flat administrative fee
The key structural difference is compensation: RACs receive a contingency fee for identified improper payments, while MACs are paid an administrative fee regardless of audit outcomes.
Question 6: A compliance officer wants to proactively identify billing patterns that may attract a RAC audit. Which internal tool is MOST useful for this purpose?
- Provider Enrollment data review
- Internal claims data analytics and comparison against CMS edit libraries (Correct answer)
- Staff credentialing file review
- HIPAA privacy impact assessment
Correct answer: Internal claims data analytics and comparison against CMS edit libraries
Analyzing internal claims data against known CMS edits and national billing benchmarks helps identify outlier patterns before external auditors do.
Question 7: When a provider repays a RAC-identified overpayment but later wins on appeal, what happens?
- The provider forfeits the repaid amount as an audit penalty
- CMS refunds the amount plus interest to the provider (Correct answer)
- The provider must refile the original claim
- The MAC issues a new demand for the amount
Correct answer: CMS refunds the amount plus interest to the provider
If a provider successfully appeals an overpayment determination, CMS refunds the recouped amount along with applicable interest.
CCT Government Audits and RACs 4
A Unified Program Integrity Contractor (UPIC) was created to replace which two legacy contractor types?