Government Audits and RACs Flashcards
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Read the first 7 Government Audits and RACs flashcards as text
A Unified Program Integrity Contractor (UPIC) was created to replace which two legacy contractor types?
Answer: ZPICs and PSCs
UPICs consolidated the functions of Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) into a single contractor.
What is the primary purpose of the OIG Work Plan in the context of government audits?
Answer: To announce planned audits, reviews, and studies for the coming fiscal year
The OIG Work Plan outlines the audits, evaluations, and inspections the OIG intends to conduct, allowing compliance officers to proactively assess risk areas.
Statistical sampling and extrapolation in a Medicare audit means that:
Answer: Findings from a reviewed sample are projected to estimate overpayments across the universe of similar claims
Extrapolation applies an error rate found in a statistical sample to the entire universe of similar claims, potentially resulting in large overpayment demands from a small sample.
Under which condition may a Medicare contractor NOT use extrapolation to expand overpayment findings?
Answer: When there is no sustained or high level of payment error and no prior education attempts
CMS policy limits the use of extrapolation to situations involving a sustained or high level of payment error or where education has failed to correct billing problems.
Which of the following is a key difference between a MAC post-payment review and a RAC audit?
Answer: RACs are paid on contingency; MACs are paid a flat administrative fee
The key structural difference is compensation: RACs receive a contingency fee for identified improper payments, while MACs are paid an administrative fee regardless of audit outcomes.
A compliance officer wants to proactively identify billing patterns that may attract a RAC audit. Which internal tool is MOST useful for this purpose?
Answer: Internal claims data analytics and comparison against CMS edit libraries
Analyzing internal claims data against known CMS edits and national billing benchmarks helps identify outlier patterns before external auditors do.
When a provider repays a RAC-identified overpayment but later wins on appeal, what happens?
Answer: CMS refunds the amount plus interest to the provider
If a provider successfully appeals an overpayment determination, CMS refunds the recouped amount along with applicable interest.