CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations Flashcards
7 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations flashcards as text
Under HIPAA, which of the following is NOT considered a covered entity?
Answer: A self-insured employer that administers its own health plan internally without using a third-party administrator
A self-insured employer acting solely in its capacity as an employer is not a covered entity; however, if it uses a TPA to administer the plan, the TPA (not the employer) is the covered entity.
The OIG's Work Plan is significant for revenue cycle compliance because it:
Answer: Identifies audit areas and billing vulnerabilities OIG plans to review in the coming year
The OIG Work Plan outlines specific topics and billing areas OIG will audit, helping compliance teams proactively self-audit those same areas.
A patient requests access to their Protected Health Information (PHI) under HIPAA. In most cases, the covered entity must provide access within:
Answer: 30 days, with one 30-day extension if needed
HIPAA requires covered entities to act on an individual's request for access to PHI within 30 days, with one 30-day extension allowed if the individual is notified in writing.
Which of the following best describes 'upcoding' in the context of healthcare billing compliance?
Answer: Billing a higher-level or more complex code than the service actually provided
Upcoding is billing a code that reflects a higher level of service or a more expensive procedure than was actually performed, which is a form of healthcare fraud.
Under the Conditions of Participation (CoPs) for Medicare, hospitals must maintain a compliance program that includes which of the following?
Answer: Written standards, training, a compliance officer, and a reporting mechanism
CMS Conditions of Participation require hospitals to have a compliance program including written policies, training, a compliance officer, and a confidential reporting system.
What is the primary purpose of the Medicare Physician Fee Schedule (MPFS) in revenue cycle management?
Answer: To determine payment amounts for services rendered by physicians and other practitioners billed under Part B
The MPFS establishes the payment rates for physician and practitioner services under Medicare Part B, based on Relative Value Units (RVUs) and a conversion factor.
A hospital receives a Recovery Audit Contractor (RAC) audit demand letter requesting medical records for a claim submitted two years ago. What is the RAC's look-back period for most claims?
Answer: 3 years
RACs can look back up to 3 years from the date the claim was filed when conducting post-payment reviews of Medicare and Medicaid claims.