CRCR Healthcare Compliance and Regulations 5 — Questions and Answers
Question 1: 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?
- A state attorney general
- A private individual (whistleblower/relator) (Correct answer)
- A Medicare Administrative Contractor
- An OIG investigator
Correct 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.
Question 2: Which HIPAA standard governs the electronic exchange of healthcare claims and requires use of standardized transaction code sets?
- Security Rule
- Privacy Rule
- Transactions and Code Sets Rule (Correct answer)
- Identifier Standards Rule
Correct 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.
Question 3: 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?
- Administrative Law Judge (ALJ) hearing
- Qualified Independent Contractor (QIC) redetermination
- Medicare Administrative Contractor (MAC) redetermination (Correct answer)
- Medicare Appeals Council review
Correct 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).
Question 4: Under the Affordable Care Act, providers who receive an overpayment must report and return the funds within how many days of identifying the overpayment?
- 30 days
- 60 days (Correct answer)
- 90 days
- 120 days
Correct answer: 60 days
The ACA's 'sixty-day rule' requires providers to report and return identified overpayments from federal programs within 60 days.
Question 5: Which type of Medicare audit uses a pre-payment review process where a contractor reviews a sample of claims before payment is made?
- Recovery Audit (RAC)
- Targeted Probe and Educate (TPE) (Correct answer)
- Comprehensive Error Rate Testing (CERT)
- Zone Program Integrity Contractor (ZPIC)
Correct 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.
Question 6: Under state insurance laws, a provider who continues to bill a payer after being notified of contract termination may be engaging in which violation?
- Breach of fiduciary duty
- Tortious interference
- Fraudulent misrepresentation
- Unauthorized billing (Correct answer)
Correct 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.
Question 7: Which federal regulation requires that Medicare Advantage and Part D plan sponsors implement a compliance program that includes a compliance officer and training?
- 42 CFR Part 422 and Part 423 (Correct answer)
- 45 CFR Part 164
- 42 CFR Part 412
- 45 CFR Part 170
Correct 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.
CRCR Healthcare Compliance and Regulations 5
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?