CRCR Regulatory and Compliance Knowledge 5 — Questions and Answers
Question 1: Which federal program requires hospitals to report quality measures and, if they fail to do so, reduces their Medicare inpatient prospective payment system update by 2%?
- Hospital Value-Based Purchasing Program
- Inpatient Quality Reporting Program (Correct answer)
- Hospital Readmissions Reduction Program
- Hospital-Acquired Condition Reduction Program
Correct answer: Inpatient Quality Reporting Program
The Inpatient Quality Reporting (IQR) Program requires hospitals to report specified quality measures or face a 2% reduction to their IPPS annual payment update.
Question 2: Under the No Surprises Act effective January 2022, what must out-of-network providers give to patients receiving non-emergency services at in-network facilities?
- A superbill within 30 days of service
- Good Faith Estimate (GFE) at least 3 business days before the service
- Written notice and consent to charge out-of-network rates at least 72 hours in advance (Correct answer)
- A summary of benefits and coverage document prior to scheduling
Correct answer: Written notice and consent to charge out-of-network rates at least 72 hours in advance
The No Surprises Act requires out-of-network providers to give written notice and obtain patient consent to charge out-of-network rates at least 72 hours before the scheduled service.
Question 3: Which entity administers the Medicare Integrity Program, which includes Recovery Audit Contractors (RACs) tasked with identifying improper payments?
- Office of Inspector General (OIG)
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- Department of Justice (DOJ)
- Office for Civil Rights (OCR)
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the Medicare Integrity Program, which authorizes RACs to audit Medicare claims and identify overpayments and underpayments.
Question 4: A provider submits a claim for a surgical procedure and separately bills for a service that is considered an integral component of that procedure. This billing error is known as:
- Upcoding
- Unbundling (Correct answer)
- Duplicate billing
- Fragmentation
Correct answer: Unbundling
Unbundling is billing separately for services that should be reported together under a single comprehensive code, violating correct coding principles.
Question 5: Under Medicaid's Federal Financial Participation (FFP) rules, what must states ensure to receive matching federal funds for Medicaid expenditures?
- All providers must be licensed in a state with a Certificate of Need law
- Expenditures must be for services that are medically necessary and covered under the approved state plan (Correct answer)
- States must maintain a Medicaid fraud unit funded entirely by state appropriations
- All Medicaid claims must be processed within 14 days of submission
Correct answer: Expenditures must be for services that are medically necessary and covered under the approved state plan
To receive FFP, Medicaid expenditures must be for services that are medically necessary, properly documented, and covered under the CMS-approved state Medicaid plan.
Question 6: Which type of Medicare audit uses automated systems to review claims for billing errors without requesting medical records from providers?
- Comprehensive Error Rate Testing (CERT)
- Automated Review (by MACs or RACs) (Correct answer)
- Pre-payment review
- Targeted Probe and Educate (TPE)
Correct answer: Automated Review (by MACs or RACs)
Automated reviews use data analysis and editing systems to identify and deny claims with clear errors—such as incorrect modifiers or unbundling—without requesting medical records.
Question 7: A hospital's compliance program identifies that its chargemaster has not been updated in three years, resulting in billing for deleted CPT codes. Which compliance framework element does this failure represent?
- Lack of written policies and procedures
- Ineffective monitoring and auditing (Correct answer)
- Failure to respond to detected offenses
- Absence of open lines of communication
Correct answer: Ineffective monitoring and auditing
Outdated chargemasters and undetected use of deleted codes reflect a failure in the monitoring and auditing element of the OIG's seven elements of an effective compliance program.
CRCR Regulatory and Compliance Knowledge 5
Which federal program requires hospitals to report quality measures and, if they fail to do so, reduces their Medicare inpatient prospective payment system update by 2%?