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 does the Deficit Reduction Act of 2005 require of states regarding Medicaid fraud reporting?
Answer: States must adopt Medicaid false claims provisions at least as strong as the federal False Claims Act to qualify for enhanced federal Medicaid funding
The DRA created financial incentives for states to enact state-level false claims acts with qui tam provisions strengthening Medicaid fraud enforcement.
What is a protected disclosure under the False Claims Act's qui tam provisions?
Answer: A whistleblower's formal filing of a sealed complaint in federal court alleging fraud against the government
The qui tam provision allows private individuals (relators) to file sealed complaints on behalf of the government triggering a government investigation.
What is the OIG's Self-Disclosure Protocol and when might an organization use it?
Answer: A formal process allowing providers to voluntarily report potential fraud and abuse violations to the OIG in exchange for reduced penalties
The SDP allows providers to proactively report compliance violations to the OIG typically resulting in lower penalties than if the violation is discovered by the government.
What is the Health Care Fraud Prevention and Enforcement Action Team?
Answer: A joint DOJ and HHS initiative that coordinates federal, state, and local law enforcement to combat Medicare and Medicaid fraud
HEAT coordinates law enforcement resources across agencies to identify, prosecute, and deter healthcare fraud and abuse in federal programs.
What is the significance of the 60-day rule in healthcare compliance?
Answer: Providers who identify an overpayment must report and return it to CMS within 60 days of identifying the overpayment
The 60-day rule requires prompt return of identified Medicare and Medicaid overpayments and failure to comply can trigger False Claims Act liability.
What is the purpose of an internal audit in healthcare compliance?
Answer: To proactively assess the organization's billing, coding, and operational practices for compliance risk, identify errors, and implement corrections before regulators discover problems
Internal audits are a proactive tool to identify compliance risks and billing errors before external auditors or regulators find them.