CRCR Regulatory and Compliance Knowledge 2

Question 1

What is a covered entity under HIPAA?

Accepted Answer

Health plans, healthcare clearinghouses, and healthcare providers that transmit health information electronically

Answer

Any business that employs healthcare workers

Answer

All businesses that collect personal data

Answer

Only hospitals and physician practices

Question 2

What are the potential penalties for a HIPAA breach resulting from willful neglect that is not corrected?

Accepted Answer

Up to $1.9 million per violation category per year plus potential criminal charges

Answer

No penalty if the organization apologizes

Answer

Only a written warning for a first offense

Answer

A $100 fine per affected patient

Question 3

What do the Conditions of Participation refer to in healthcare compliance?

Accepted Answer

Federal standards that healthcare facilities must meet to participate in the Medicare and Medicaid programs

Answer

Patient consent forms required before surgery

Answer

State licensing requirements for physicians

Answer

The terms of a hospital's private insurance contracts

Question 4

What is the role of CMS in US healthcare compliance?

Accepted Answer

To administer Medicare and Medicaid, set coverage policies, issue billing regulations, and establish quality standards for participating providers

Answer

To prosecute healthcare fraud on behalf of the DOJ

Answer

To license physicians and other healthcare professionals

Answer

To investigate insurance company rate increases

Question 5

What is exclusion from Medicare and Medicaid participation and what triggers it?

Accepted 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

Answer

A patient's inability to use Medicare due to age

Answer

A voluntary decision by a provider to leave the Medicare network

Answer

A temporary suspension of billing privileges for late claims

Question 6

What is the Medicare Appeals Council in the context of the Medicare appeals process?

Accepted Answer

The fourth level of the Medicare appeals process following an ALJ hearing where Medicare beneficiaries and providers can appeal ALJ decisions

Answer

The first level of appeal after a Medicare denial

Answer

A private review organization contracted by CMS

Answer

A CMS committee that approves new Medicare coverage policies