CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 3 — Questions and Answers
Question 1: Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?
- $5,500
- $11,000
- $21,916 (Correct answer)
- $50,000
Correct answer: $21,916
As of recent adjustments for inflation, the False Claims Act penalty range is approximately $13,946 to $27,894 per false claim (the lower bound was ~$21,916 in recent years); the exact figure adjusts annually, but answer C reflects the updated floor most commonly tested.
Question 2: Which federal agency is primarily responsible for enforcing the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules?
- Centers for Medicare & Medicaid Services (CMS)
- Office for Civil Rights (OCR) (Correct answer)
- Office of Inspector General (OIG)
- Department of Justice (DOJ)
Correct answer: Office for Civil Rights (OCR)
The HHS Office for Civil Rights (OCR) is the primary enforcer of HIPAA Privacy and Security Rules for covered entities and business associates.
Question 3: A revenue cycle employee discovers that a supervisor is upcoding claims to increase reimbursement. Under the False Claims Act's qui tam provisions, what can the employee do?
- Only report internally to the compliance officer
- File a whistleblower lawsuit on behalf of the government and potentially receive a portion of recovered funds (Correct answer)
- Report to the state licensing board only
- Submit an anonymous tip to the OIG with no legal protections
Correct answer: File a whistleblower lawsuit on behalf of the government and potentially receive a portion of recovered funds
Qui tam provisions allow private individuals (relators) to file suit on behalf of the government and receive 15–30% of recovered funds, with anti-retaliation protections.
Question 4: The Stark Law (Physician Self-Referral Law) prohibits physicians from referring patients for designated health services (DHS) to entities where the physician has a financial relationship UNLESS:
- The services are medically necessary
- A specific statutory or regulatory exception applies (Correct answer)
- The patient provides written consent
- The referring physician discloses the relationship verbally
Correct answer: A specific statutory or regulatory exception applies
Stark Law is a strict liability statute — violations occur regardless of intent unless a specific exception (e.g., in-office ancillary services, bona fide employment) is met.
Question 5: What distinguishes the Anti-Kickback Statute (AKS) from the Stark Law in terms of intent?
- Stark Law requires proof of criminal intent; AKS does not
- AKS requires proof of intent to induce referrals; Stark Law is strict liability (Correct answer)
- Both require proof of intent to violate
- Neither requires intent; both are strict liability
Correct answer: AKS requires proof of intent to induce referrals; Stark Law is strict liability
The AKS is an intent-based criminal statute requiring knowing and willful conduct to induce referrals, while Stark Law is a strict civil liability statute requiring no proof of intent.
Question 6: A hospital's compliance program discovers a billing error that resulted in overpayment from Medicare. Under the 60-day rule, when must the overpayment be reported and returned?
- Within 30 days of identification
- Within 60 days of identification or the date of a corresponding cost report, whichever is later (Correct answer)
- Within 90 days of the end of the fiscal year
- Within 120 days after the annual audit
Correct answer: Within 60 days of identification or the date of a corresponding cost report, whichever is later
The ACA's 60-day rule requires that identified Medicare/Medicaid overpayments be reported and returned within 60 days of identification, or the overpayment becomes a false claim.
Question 7: Which OIG compliance program guidance element is considered the foundation for detecting and preventing fraud in a healthcare organization?
- Disciplinary standards and enforcement
- Written policies and procedures (Correct answer)
- Open lines of communication
- Conducting internal monitoring and auditing
Correct answer: Written policies and procedures
Written policies and procedures are the foundational element because they establish the organization's compliance standards and provide the framework all other elements build upon.
CRCR CRCR - Certified Revenue Cycle Representative Program Healthcare Compliance and Regulations 3
Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?