CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations Flashcards

Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?

Answer: $21,916

As of recent adjustments for inflation, the False Claims Act penalty range is approximately $13,946 to $27,894 per false claim (the lower bound was ~$21,916 in recent years); the exact figure adjusts annually, but answer C reflects the updated floor most commonly tested.

Which federal agency is primarily responsible for enforcing the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules?

Answer: Office for Civil Rights (OCR)

The HHS Office for Civil Rights (OCR) is the primary enforcer of HIPAA Privacy and Security Rules for covered entities and business associates.

A revenue cycle employee discovers that a supervisor is upcoding claims to increase reimbursement. Under the False Claims Act's qui tam provisions, what can the employee do?

Answer: File a whistleblower lawsuit on behalf of the government and potentially receive a portion of recovered funds

Qui tam provisions allow private individuals (relators) to file suit on behalf of the government and receive 15–30% of recovered funds, with anti-retaliation protections.

The Stark Law (Physician Self-Referral Law) prohibits physicians from referring patients for designated health services (DHS) to entities where the physician has a financial relationship UNLESS:

Answer: A specific statutory or regulatory exception applies

Stark Law is a strict liability statute — violations occur regardless of intent unless a specific exception (e.g., in-office ancillary services, bona fide employment) is met.

What distinguishes the Anti-Kickback Statute (AKS) from the Stark Law in terms of intent?

Answer: AKS requires proof of intent to induce referrals; Stark Law is strict liability

The AKS is an intent-based criminal statute requiring knowing and willful conduct to induce referrals, while Stark Law is a strict civil liability statute requiring no proof of intent.

A hospital's compliance program discovers a billing error that resulted in overpayment from Medicare. Under the 60-day rule, when must the overpayment be reported and returned?

Answer: Within 60 days of identification or the date of a corresponding cost report, whichever is later

The ACA's 60-day rule requires that identified Medicare/Medicaid overpayments be reported and returned within 60 days of identification, or the overpayment becomes a false claim.

Which OIG compliance program guidance element is considered the foundation for detecting and preventing fraud in a healthcare organization?

Answer: Written policies and procedures

Written policies and procedures are the foundational element because they establish the organization's compliance standards and provide the framework all other elements build upon.