Compliance & Regulatory Requirements Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Compliance & Regulatory Requirements flashcards as text
Under the 60-Day Overpayment Rule, when does the 60-day clock begin for an MA plan discovering risk adjustment overpayments?
Answer: When the plan first identifies or should have identified the overpayment through reasonable diligence
The clock starts when the overpayment is identified or should have been identified. Plans cannot delay audits to delay the clock.
An MA plan contracts with a vendor for retrospective chart reviews. Which OIG compliance concern is most relevant?
Answer: Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support
Chart review vendors paid to find HCC gaps have an inherent incentive to add diagnoses that may not be fully supported.
Which regulatory body has primary authority over Medicare Advantage risk adjustment compliance?
Answer: CMS through its Center for Program Integrity
CMS/CPI administers RADV, sets data submission requirements, and enforces compliance. DOJ may pursue FCA cases, but CMS is primary.
A provider's documentation consistently uses copy-forward, resulting in identical problem lists across encounters. What compliance concern does this raise?
Answer: Significant concern that diagnoses may be perpetuated without active clinical assessment
Diagnoses may be perpetuated without the provider actively assessing whether each condition is still present and relevant.
What is the minimum coding intensity adjustment CMS applies to MA risk adjustment payments?
Answer: A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences
The 5.91% reduction accounts for the documented fact that MA plans capture more diagnoses than FFS Medicare.
An MA plan receives a qui tam complaint alleging risk adjustment fraud. What protections does the whistleblower have?
Answer: Protection from retaliation, 15-30% of government recovery, and right to participate in proceedings
The FCA provides anti-retaliation protection, a financial share of recovery, and the right to participate in litigation.