Regulatory and Compliance Knowledge 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 Regulatory and Compliance Knowledge flashcards as text
Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?
Answer: $5,500
The False Claims Act imposes civil monetary penalties of $5,500 to $11,000 per false claim, plus three times the damages sustained by the government.
Which federal statute prohibits healthcare providers from referring Medicare patients to entities with which the provider has a financial relationship, absent an applicable exception?
Answer: Stark Law (Physician Self-Referral Law)
The Stark Law (42 U.S.C. § 1395nn) prohibits physician self-referrals for designated health services payable by Medicare unless a specific exception applies.
A hospital discovers it overbilled Medicare by $50,000 due to a coding error. Under the 60-day rule, within how many days must the overpayment be reported and returned after identification?
Answer: 60 days
The ACA's 60-day rule requires providers to report and return identified Medicare/Medicaid overpayments within 60 days of identification.
Which HIPAA standard governs the electronic transmission of healthcare claim information and requires use of specific transaction code sets?
Answer: Transactions and Code Sets Rule
The HIPAA Transactions and Code Sets Rule mandates standard formats (such as the 837P/837I) and code sets (ICD-10, CPT) for electronic healthcare transactions.
Under EMTALA, what is a hospital's obligation when a patient presents to the emergency department with an emergency medical condition?
Answer: Provide a medical screening examination and stabilizing treatment regardless of ability to pay
EMTALA requires hospitals to provide an appropriate medical screening examination and stabilizing treatment to any patient presenting with an emergency medical condition, regardless of payment status.
Which OIG exclusion type permanently bars an individual or entity from participation in federal healthcare programs without possibility of reinstatement?
Answer: Mandatory exclusion
Mandatory exclusions under 42 U.S.C. § 1320a-7(a) are required by law for certain offenses (e.g., convictions related to patient abuse) and, in some cases, are permanent.
A compliance officer notices that a physician consistently documents 99215 (high-complexity E&M) for visits that appear to warrant only 99213. This pattern most likely indicates which compliance risk?
Answer: Upcoding
Upcoding occurs when a provider bills for a higher-level service than was actually documented or provided, inflating reimbursement.