CCT Government Audits and RACs 5 — Questions and Answers
Question 1: Which federal law established the False Claims Act (FCA) liability for knowingly retaining Medicare overpayments beyond the 60-day repayment window?
- HIPAA (1996)
- Balanced Budget Act (1997)
- Affordable Care Act (2010) (Correct answer)
- Medicare Modernization Act (2003)
Correct 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.
Question 2: 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?
- The practice has unusually high utilization of high-complexity E/M codes compared to peers (Correct answer)
- The practice recently enrolled in Medicare
- The practice changed billing software
- The physician retired mid-year
Correct 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.
Question 3: An Administrative Law Judge (ALJ) hearing is which level of the Medicare appeals process?
- Level 1
- Level 2
- Level 3 (Correct answer)
- Level 4
Correct 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).
Question 4: Which of the following scenarios would most likely trigger a UPIC fraud investigation rather than a standard RAC audit?
- A hospital billed the wrong DRG code due to a documentation deficiency
- A DME supplier billed for equipment never delivered to beneficiaries (Correct answer)
- A physician practice had documentation that did not support a code level
- A skilled nursing facility billed one therapy unit above what records supported
Correct 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.
Question 5: What does 'probe and educate' refer to in the context of MAC post-payment reviews?
- An FBI-led investigation into fraudulent billing networks
- A targeted small-scale review followed by provider education before full-scale audit action (Correct answer)
- A process for enrolling new providers in Medicare
- A CMS initiative to educate beneficiaries about their Medicare rights
Correct 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.
Question 6: A compliance officer learns that a competitor was audited for a specific billing practice. According to best compliance practices, the officer should:
- Ignore the audit since it involved a competitor
- Conduct an internal self-audit of the same billing practice in their own organization (Correct answer)
- Report the competitor to the OIG
- Request a CMS advisory opinion on the practice
Correct 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.
Question 7: Which best describes the role of a Compliance Technician when a RAC demand letter is received?
- Immediately repay the full amount without review to avoid interest
- Coordinate record retrieval, evaluate the findings, and support the appeals decision (Correct answer)
- Refer the matter entirely to outside legal counsel and take no further internal action
- Notify the OIG of the audit finding within 5 business days
Correct 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.
CCT Government Audits and RACs 5
Which federal law established the False Claims Act (FCA) liability for knowingly retaining Medicare overpayments beyond the 60-day repayment window?