Healthcare Compliance and Regulations 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 Healthcare Compliance and Regulations flashcards as text
The qui tam provision of the False Claims Act allows which party to file a lawsuit on behalf of the government and receive a share of recovered funds?
Answer: A private individual (whistleblower/relator)
The qui tam provision lets private individuals (relators) file FCA lawsuits on the government's behalf and receive 15–30% of funds recovered.
Which HIPAA standard governs the electronic exchange of healthcare claims and requires use of standardized transaction code sets?
Answer: Transactions and Code Sets Rule
HIPAA's Transactions and Code Sets Rule mandates use of standardized electronic formats (e.g., 837P, 837I) and code sets (ICD-10, CPT) for healthcare transactions.
A provider receives a demand letter from a Recovery Audit Contractor (RAC) claiming an overpayment. What is the first level of the Medicare claims appeals process?
Answer: Medicare Administrative Contractor (MAC) redetermination
The first level of Medicare's five-level appeals process is a redetermination request submitted to the Medicare Administrative Contractor (MAC).
Under the Affordable Care Act, providers who receive an overpayment must report and return the funds within how many days of identifying the overpayment?
Answer: 60 days
The ACA's 'sixty-day rule' requires providers to report and return identified overpayments from federal programs within 60 days.
Which type of Medicare audit uses a pre-payment review process where a contractor reviews a sample of claims before payment is made?
Answer: Targeted Probe and Educate (TPE)
Targeted Probe and Educate (TPE) involves pre-payment and post-payment review of a sample of claims, followed by provider education to reduce error rates.
Under state insurance laws, a provider who continues to bill a payer after being notified of contract termination may be engaging in which violation?
Answer: Unauthorized billing
Billing a payer after contract termination constitutes unauthorized billing, as the provider no longer has a valid contractual basis for reimbursement at contracted rates.
Which federal regulation requires that Medicare Advantage and Part D plan sponsors implement a compliance program that includes a compliance officer and training?
Answer: 42 CFR Part 422 and Part 423
42 CFR Parts 422 (Medicare Advantage) and 423 (Part D) mandate that plan sponsors establish effective compliance programs with required elements including a compliance officer.