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
Which federal program requires hospitals to report quality measures and, if they fail to do so, reduces their Medicare inpatient prospective payment system update by 2%?
Answer: Inpatient Quality Reporting Program
The Inpatient Quality Reporting (IQR) Program requires hospitals to report specified quality measures or face a 2% reduction to their IPPS annual payment update.
Under the No Surprises Act effective January 2022, what must out-of-network providers give to patients receiving non-emergency services at in-network facilities?
Answer: Written notice and consent to charge out-of-network rates at least 72 hours in advance
The No Surprises Act requires out-of-network providers to give written notice and obtain patient consent to charge out-of-network rates at least 72 hours before the scheduled service.
Which entity administers the Medicare Integrity Program, which includes Recovery Audit Contractors (RACs) tasked with identifying improper payments?
Answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the Medicare Integrity Program, which authorizes RACs to audit Medicare claims and identify overpayments and underpayments.
A provider submits a claim for a surgical procedure and separately bills for a service that is considered an integral component of that procedure. This billing error is known as:
Answer: Unbundling
Unbundling is billing separately for services that should be reported together under a single comprehensive code, violating correct coding principles.
Under Medicaid's Federal Financial Participation (FFP) rules, what must states ensure to receive matching federal funds for Medicaid expenditures?
Answer: Expenditures must be for services that are medically necessary and covered under the approved state plan
To receive FFP, Medicaid expenditures must be for services that are medically necessary, properly documented, and covered under the CMS-approved state Medicaid plan.
Which type of Medicare audit uses automated systems to review claims for billing errors without requesting medical records from providers?
Answer: Automated Review (by MACs or RACs)
Automated reviews use data analysis and editing systems to identify and deny claims with clear errors—such as incorrect modifiers or unbundling—without requesting medical records.
A hospital's compliance program identifies that its chargemaster has not been updated in three years, resulting in billing for deleted CPT codes. Which compliance framework element does this failure represent?
Answer: Ineffective monitoring and auditing
Outdated chargemasters and undetected use of deleted codes reflect a failure in the monitoring and auditing element of the OIG's seven elements of an effective compliance program.