Regulatory Compliance & Risk Management Flashcards
7 cards from real CDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory Compliance & Risk Management flashcards as text
Under the No Surprises Act (as applied to dental benefits), the primary protection for patients involves:
Answer: Limiting unexpected balance billing by out-of-network providers in specific emergency and facility settings
The No Surprises Act protects patients from unexpected out-of-network bills primarily in emergency and certain facility-based settings, limiting balance billing.
A dental plan's Explanation of Benefits (EOB) must, at minimum, include which element to comply with ERISA disclosure requirements?
Answer: The specific reason for any denial and instructions on how to appeal
ERISA requires EOBs to include the reason for any adverse benefit determination and instructions for initiating the plan's appeals process.
In dental risk management, the term 'tail coverage' in a professional liability context refers to:
Answer: Malpractice coverage for claims filed after a claims-made policy has ended for incidents during the policy period
Tail coverage (extended reporting endorsement) covers claims reported after a claims-made policy ends for incidents that occurred during the active policy period.
A dental benefits organization seeking URAC accreditation for its dental utilization management program must demonstrate that clinical reviewers are:
Answer: Licensed dentists or other qualified dental professionals appropriate to the clinical issue under review
URAC UM accreditation requires that clinical review decisions be made by professionals with appropriate dental credentials matched to the clinical content of the review.
A dental consultant discovers that a provider's claim submission contains altered radiographic images. The most appropriate immediate action is to:
Answer: Suspend the claim, document findings, and refer to the Special Investigations Unit (SIU) or fraud unit
Altered documentation is a serious fraud indicator requiring immediate claim suspension and referral to the SIU for formal investigation.
Under state insurance regulations, a dental plan's utilization management denial based on lack of medical necessity must be reviewed on appeal by:
Answer: A dental professional who was not involved in the original denial decision
Most state UM regulations and URAC standards require that clinical appeal reviews be conducted by a different reviewer than the one who issued the initial denial.
A dental plan must report overpayments identified through a self-audit to CMS under the ACA's 60-day rule. Failure to report and return the overpayment within 60 days of identification results in:
Answer: Potential False Claims Act liability for retention of a known overpayment
The ACA's 60-day rule treats knowing retention of a Medicare/Medicaid overpayment beyond the deadline as a reverse false claim under the FCA.