CCT Government Audits and RACs 5

Question 1

Which federal law established the False Claims Act (FCA) liability for knowingly retaining Medicare overpayments beyond the 60-day repayment window?

Accepted Answer

Affordable Care Act (2010)

Answer

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?

Accepted Answer

The practice has unusually high utilization of high-complexity E/M codes compared to peers

Answer

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?

Accepted Answer

Level 3

Answer

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?

Accepted Answer

A DME supplier billed for equipment never delivered to beneficiaries

Answer

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?

Accepted Answer

A targeted small-scale review followed by provider education before full-scale audit action

Answer

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.

(CCT) Certified Compliance Technician Practice Test

(CCT) Certified Compliance Technician Practice Test

CCT Government Audits and RACs 5