CRCR Regulatory and Compliance Knowledge 4 — 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 (Correct answer)
- $11,000
- $22,000
- $50,000
Correct answer: $5,500
The False Claims Act imposes civil monetary penalties of $5,500 to $11,000 per false claim, plus three times the damages sustained by the government.
Question 2: Which federal statute prohibits healthcare providers from referring Medicare patients to entities with which the provider has a financial relationship, absent an applicable exception?
- Anti-Kickback Statute
- Stark Law (Physician Self-Referral Law) (Correct answer)
- False Claims Act
- EMTALA
Correct answer: Stark Law (Physician Self-Referral Law)
The Stark Law (42 U.S.C. § 1395nn) prohibits physician self-referrals for designated health services payable by Medicare unless a specific exception applies.
Question 3: A hospital discovers it overbilled Medicare by $50,000 due to a coding error. Under the 60-day rule, within how many days must the overpayment be reported and returned after identification?
- 30 days
- 60 days (Correct answer)
- 90 days
- 120 days
Correct answer: 60 days
The ACA's 60-day rule requires providers to report and return identified Medicare/Medicaid overpayments within 60 days of identification.
Question 4: Which HIPAA standard governs the electronic transmission of healthcare claim information and requires use of specific transaction code sets?
- Privacy Rule
- Security Rule
- Transactions and Code Sets Rule (Correct answer)
- Breach Notification Rule
Correct answer: Transactions and Code Sets Rule
The HIPAA Transactions and Code Sets Rule mandates standard formats (such as the 837P/837I) and code sets (ICD-10, CPT) for electronic healthcare transactions.
Question 5: Under EMTALA, what is a hospital's obligation when a patient presents to the emergency department with an emergency medical condition?
- Collect a copayment before providing treatment
- Provide a medical screening examination and stabilizing treatment regardless of ability to pay (Correct answer)
- Transfer the patient immediately to a facility that accepts their insurance
- Obtain prior authorization from the payer before rendering care
Correct answer: Provide a medical screening examination and stabilizing treatment regardless of ability to pay
EMTALA requires hospitals to provide an appropriate medical screening examination and stabilizing treatment to any patient presenting with an emergency medical condition, regardless of payment status.
Question 6: Which OIG exclusion type permanently bars an individual or entity from participation in federal healthcare programs without possibility of reinstatement?
- Permissive exclusion
- Mandatory exclusion (Correct answer)
- Temporary suspension
- Conditional exclusion
Correct answer: Mandatory exclusion
Mandatory exclusions under 42 U.S.C. § 1320a-7(a) are required by law for certain offenses (e.g., convictions related to patient abuse) and, in some cases, are permanent.
Question 7: A compliance officer notices that a physician consistently documents 99215 (high-complexity E&M) for visits that appear to warrant only 99213. This pattern most likely indicates which compliance risk?
- Unbundling
- Upcoding (Correct answer)
- Duplicate billing
- Phantom billing
Correct answer: Upcoding
Upcoding occurs when a provider bills for a higher-level service than was actually documented or provided, inflating reimbursement.
CRCR Regulatory and Compliance Knowledge 4
Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?