Regulatory and Compliance Knowledge Flashcards
6 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 6 Regulatory and Compliance Knowledge flashcards as text
What is a covered entity under HIPAA?
Answer: Health plans, healthcare clearinghouses, and healthcare providers that transmit health information electronically
HIPAA's covered entity definition includes health plans, clearinghouses, and any provider that transmits PHI electronically in connection with standard transactions.
What are the potential penalties for a HIPAA breach resulting from willful neglect that is not corrected?
Answer: Up to $1.9 million per violation category per year plus potential criminal charges
HIPAA's tiered penalty structure imposes the highest fines for willful neglect that is not corrected.
What do the Conditions of Participation refer to in healthcare compliance?
Answer: Federal standards that healthcare facilities must meet to participate in the Medicare and Medicaid programs
CoPs are CMS's baseline standards for quality and patient safety that must be met for facilities to participate in Medicare and Medicaid.
What is the role of CMS in US healthcare compliance?
Answer: To administer Medicare and Medicaid, set coverage policies, issue billing regulations, and establish quality standards for participating providers
CMS is the federal agency responsible for operating Medicare and Medicaid and setting the regulatory framework for both programs.
What is exclusion from Medicare and Medicaid participation and what triggers it?
Answer: A federal sanction that bars an individual or entity from billing Medicare or Medicaid triggered by fraud convictions, license revocations, or other specified conduct
OIG exclusion bars individuals and entities from participation in federal healthcare programs which is one of the most serious compliance sanctions available.
What is the Medicare Appeals Council in the context of the Medicare appeals process?
Answer: The fourth level of the Medicare appeals process following an ALJ hearing where Medicare beneficiaries and providers can appeal ALJ decisions
The Medicare Appeals Council is the fourth of five levels of Medicare appeals for Part A and Part B disputes.