CRCR Healthcare Compliance and Regulations 5

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?

Accepted Answer

A private individual (whistleblower/relator)

Answer

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?

Accepted Answer

Transactions and Code Sets Rule

Answer

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?

Accepted Answer

Medicare Administrative Contractor (MAC) redetermination

Answer

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?

Accepted Answer

60 days

Answer

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?

Accepted Answer

Targeted Probe and Educate (TPE)

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Healthcare Compliance and Regulations 5