CERTIFIED REVENUE CYCLE REPRESENTATIVE
KEY CONCEPTS AND PROCEDURES GUIDE
2026
◉ What is the purpose of a compliance program? Answer: Mitigate
potential fraud and abuse in the industry-specific key risk areas
◉ What is important about an effective corporate compliance
program? Answer: A program that embodies many elements to
create a program that is transparent, clearly articulated and
emphasized at all employee levels as a seriously held personal and
organizational responsibility, one that relies on full communication
inside and outside the organization
◉ What is a CCO Answer: Chief compliance officer - they typically
report directly to the board of directors/trustees as well as the chief
executive officer, and has limited responsibilities for other
operational aspects of the organization
◉ What are the situations where another payer may be completely
responsible for payment? Answer: Work-related accidents, black
lung program services, patient is enrolled in Medicare Advantage,
Federal grant programs
,◉ Under Medicare rules, certain outpatient services that are
provided within three days of the admission date, by hospitals or by
entities owned or controlled by hospitals, must be billed as part of
an inpatient stay. Answer: TRUE
◉ The OIG has issued compliance guidance/model compliance plans
for all of the following entities: Answer: hospices. physician
practices. ambulance providers
◉ Providers who are found to be in violation of CMS regulations are
subject to: Answer: Corporate integrity agreements
◉ What MSP situation requires LGHP Answer: Disability
◉ The disadvantages of outsourcing include all of the following
EXCEPT:
a) The impact of customer service or patient relations
b) The impact of loss of direct control of accounts receivable services
c) Increased costs due to vendor ineffectiveness
d) Reduced internal staffing costs and a reliance on outsourced staff
Answer: D
◉ The Medicare fee-for service appeal process for both beneficiaries
and providers
,includes all of the following levels EXCEPT:
a) Medical necessity review by an independent physician's panel
b) Judicial review by a federal district court
c) Redetermination by the company that handles claims for
Medicare
d) Review by the Medicare Appeals Council (Appeals Council)
Answer: B
◉ Business ethics, or organizational ethics represent:
a) The principles and standards by which organizations operate
b) Regulations that must be followed by law
c) Definitions of appropriate customer service
d) The code of acceptable conduct Answer: A
◉ A portion of the accounts receivable inventory which has NOT
qualified for billing
includes:
a) Charitable pledges
b) Accounts created during pre-registration but not activated
, c) Accounts coded but held within the suspense period
d) Accounts assigned to a pre-collection agency Answer: A
◉ Local Coverage Determinations (LCD) and National Coverage
Determinations (NCD) are
Medicare established guideline(s) used to determine:
a) Medicare and Medicaid provider eligibility
b) Medicare outpatient reimbursement rates
c) Which diagnoses, signs, or symptoms are reimbursable
d) What Medicare reimburses and what should be referred to
Medicaid Answer: C
◉ Days in A/R is calculated based on the value of:
a) The total accounts receivable on a specific date
b) Total anticipated revenue minus expenses
c) The time it takes to collect anticipated revenue
d) Total cash received to date Answer: C
KEY CONCEPTS AND PROCEDURES GUIDE
2026
◉ What is the purpose of a compliance program? Answer: Mitigate
potential fraud and abuse in the industry-specific key risk areas
◉ What is important about an effective corporate compliance
program? Answer: A program that embodies many elements to
create a program that is transparent, clearly articulated and
emphasized at all employee levels as a seriously held personal and
organizational responsibility, one that relies on full communication
inside and outside the organization
◉ What is a CCO Answer: Chief compliance officer - they typically
report directly to the board of directors/trustees as well as the chief
executive officer, and has limited responsibilities for other
operational aspects of the organization
◉ What are the situations where another payer may be completely
responsible for payment? Answer: Work-related accidents, black
lung program services, patient is enrolled in Medicare Advantage,
Federal grant programs
,◉ Under Medicare rules, certain outpatient services that are
provided within three days of the admission date, by hospitals or by
entities owned or controlled by hospitals, must be billed as part of
an inpatient stay. Answer: TRUE
◉ The OIG has issued compliance guidance/model compliance plans
for all of the following entities: Answer: hospices. physician
practices. ambulance providers
◉ Providers who are found to be in violation of CMS regulations are
subject to: Answer: Corporate integrity agreements
◉ What MSP situation requires LGHP Answer: Disability
◉ The disadvantages of outsourcing include all of the following
EXCEPT:
a) The impact of customer service or patient relations
b) The impact of loss of direct control of accounts receivable services
c) Increased costs due to vendor ineffectiveness
d) Reduced internal staffing costs and a reliance on outsourced staff
Answer: D
◉ The Medicare fee-for service appeal process for both beneficiaries
and providers
,includes all of the following levels EXCEPT:
a) Medical necessity review by an independent physician's panel
b) Judicial review by a federal district court
c) Redetermination by the company that handles claims for
Medicare
d) Review by the Medicare Appeals Council (Appeals Council)
Answer: B
◉ Business ethics, or organizational ethics represent:
a) The principles and standards by which organizations operate
b) Regulations that must be followed by law
c) Definitions of appropriate customer service
d) The code of acceptable conduct Answer: A
◉ A portion of the accounts receivable inventory which has NOT
qualified for billing
includes:
a) Charitable pledges
b) Accounts created during pre-registration but not activated
, c) Accounts coded but held within the suspense period
d) Accounts assigned to a pre-collection agency Answer: A
◉ Local Coverage Determinations (LCD) and National Coverage
Determinations (NCD) are
Medicare established guideline(s) used to determine:
a) Medicare and Medicaid provider eligibility
b) Medicare outpatient reimbursement rates
c) Which diagnoses, signs, or symptoms are reimbursable
d) What Medicare reimburses and what should be referred to
Medicaid Answer: C
◉ Days in A/R is calculated based on the value of:
a) The total accounts receivable on a specific date
b) Total anticipated revenue minus expenses
c) The time it takes to collect anticipated revenue
d) Total cash received to date Answer: C
