Compliance & Regulatory Knowledge Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Compliance & Regulatory Knowledge flashcards as text
Under HIPAA, which action by a covered entity constitutes a breach requiring patient notification?
Answer: An employee viewing a celebrity patient's records out of curiosity
Unauthorized access to PHI for non-treatment, non-payment, and non-operations purposes—such as curiosity—constitutes a HIPAA breach requiring notification.
The False Claims Act allows private individuals to file lawsuits on behalf of the government through which mechanism?
Answer: Qui tam provisions
The False Claims Act's qui tam provisions allow whistleblowers (relators) to sue on the government's behalf and receive a portion of any recovery.
A medical coder discovers a pattern of upcoding in claims submitted over the past year. What is the FIRST recommended step under a compliance program?
Answer: Report findings to the compliance officer or hotline
Compliance programs require employees to report suspected violations internally to the compliance officer or designated hotline as the first step.
Which federal regulation governs the Medicare Advantage (Part C) program's coding and risk adjustment requirements?
Answer: 42 CFR Part 422
42 CFR Part 422 governs Medicare Advantage organizations, including risk adjustment data validation (RADV) audits and coding accuracy requirements.
What is the primary purpose of the OIG's List of Excluded Individuals/Entities (LEIE)?
Answer: To prevent Medicare and Medicaid payment to sanctioned individuals or entities
The LEIE identifies individuals and entities excluded from participation in federal healthcare programs; billing for services by excluded parties results in significant penalties.
A hospital's compliance audit finds that 15% of DRG assignments were incorrect, leading to overpayments. Which is the CORRECT course of action?
Answer: Self-disclose and repay the overpayments to CMS within 60 days
The ACA's 60-day rule requires providers to report and return identified overpayments to federal healthcare programs within 60 days of identification.
Which element is NOT one of the seven components recommended in the OIG's Compliance Program Guidance for hospitals?
Answer: Annual patient satisfaction surveys
Patient satisfaction surveys are not among the OIG's seven recommended compliance program elements; the seven focus on internal controls, training, auditing, and reporting.