Government Audits and RACs Flashcards
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Read the first 7 Government Audits and RACs flashcards as text
The Comprehensive Error Rate Testing (CERT) program is designed to measure which of the following?
Answer: The Medicare fee-for-service improper payment rate
CERT measures the Medicare fee-for-service improper payment rate by reviewing a random sample of paid claims each year.
A Zone Program Integrity Contractor (ZPIC) differs from a RAC primarily because ZPICs focus on:
Answer: Fraud investigations and law enforcement referrals
ZPICs (now largely succeeded by UPICs) are focused on investigating suspected fraud and can refer cases to law enforcement, unlike RACs which focus on payment accuracy.
Which of the following best describes an 'automated review' conducted by a RAC?
Answer: A claim review based solely on data analysis without requesting medical records
Automated reviews use claims data and logic edits to identify clear payment errors without requiring the provider to submit medical records.
Under the RAC program, how are RAC contractors typically compensated?
Answer: Contingency fee based on improper payments identified
RACs are paid on a contingency fee basis, receiving a percentage of the overpayments collected and underpayments identified.
A provider receives a RAC Additional Documentation Request (ADR). What is the maximum number of medical records a RAC can request from a single provider within a 45-day period?
Answer: Varies by provider type and size
CMS establishes ADR limits based on provider type and claim volume to prevent administrative burden, and these limits vary accordingly.
Which Medicare administrative appeals level involves review by a Qualified Independent Contractor (QIC)?
Answer: Level 2 – Reconsideration
Level 2 reconsideration is performed by a Qualified Independent Contractor (QIC), which is independent of the MAC that handled the Level 1 redetermination.
During a government audit, a hospital discovers that it self-overpaid a Medicare cost report. Under the 60-day rule, the hospital must:
Answer: Report and return the overpayment within 60 days of identification
The 60-day rule (ACA Section 6402) requires providers to report and return identified Medicare/Medicaid overpayments within 60 days of identification or face False Claims Act liability.