Healthcare Analyst Risk Assessment & Compliance Flashcards

A healthcare organization receives a Civil Investigative Demand (CID) from the Department of Justice. What does this indicate?

Answer: The DOJ is investigating potential False Claims Act violations

A Civil Investigative Demand is a formal legal tool used by the DOJ to gather documents and testimony during a False Claims Act investigation, before any lawsuit is filed.

What is the key difference between a Recovery Audit Contractor (RAC) audit and a Comprehensive Error Rate Testing (CERT) audit?

Answer: RAC audits focus on improper payments using contingency-fee contractors; CERT audits measure the national Medicare fee-for-service error rate

RAC auditors work on contingency (keeping a percentage of recovered overpayments) to identify improper payments, while CERT is a CMS program that statistically measures the national Medicare error rate.

A healthcare compliance analyst identifies a pattern of backdated medical records following a patient complaint. This is most appropriately classified as:

Answer: Medical record falsification, which may constitute fraud

Backdating medical records to alter the documented timeline of care is considered falsification of records, which can constitute healthcare fraud under federal and state law.

In the context of healthcare risk management, 'risk transfer' is best exemplified by:

Answer: Purchasing malpractice liability insurance

Risk transfer involves shifting the financial consequences of a risk to another party — most commonly through insurance, which transfers the financial impact of malpractice claims to an insurer.

Which HHS enforcement office is primarily responsible for investigating HIPAA Privacy and Security Rule violations?

Answer: Office for Civil Rights (OCR)

HHS Office for Civil Rights (OCR) is the primary enforcement authority for HIPAA Privacy and Security Rules, investigating complaints and imposing civil monetary penalties.

A healthcare analyst is tasked with assessing supply chain risk. Which scenario represents the greatest compliance vulnerability?

Answer: A medical device manufacturer without FDA 510(k) clearance for a product being used clinically

Using a medical device without required FDA 510(k) clearance or premarket approval violates federal law and exposes the organization to significant regulatory and patient safety liability.

When conducting a healthcare fraud risk assessment, which data source would BEST help an analyst identify high-risk providers within a health system?

Answer: Claims data benchmarked against specialty peer groups

Comparing a provider's claims data to peer group benchmarks allows analysts to identify statistically unusual billing patterns that may indicate fraud, waste, or abuse.