CIC- Ch. 11 questions with verified answers
Define abuse Ans✓✓✓ payment for items or services billed by mistake
by providers, but that Medicare should not pay, including billing for
non-covered services, misusing codes on the claim, or inappropriately
allocating costs on a cost report
Define ALJ Ans✓✓✓ Administrative Law Judge- must have at least
$160 remaining in controversy to reach this level
Define Anti-Kickback Statute Ans✓✓✓ Makes it a criminal offense to
knowingly and willfully offer, pay or solicit, or receive any remuneration
to induce or reward referrals of items or services reimbursable by a
federal healthcare program
Define fraud Ans✓✓✓ the intentional deception or misrepresentation
that an individual knows to be false and makes, knowing the deception
could result in some unauthorized benefit to himself or some other
person
Define reconsideration Ans✓✓✓ a qualified independent contractor
conducts this appeal, which consists of a panel of healthcare
professionals conducting an independent review of medical necessity
issues
Define Recovery Audit Contractors (RAC) Ans✓✓✓ Program created
through the Medicare Modernization Act to identify and recover
, improper Medicare payments paid to healthcare providers under fee-
for-service (FFS) Medicare plans
Define redetermination Ans✓✓✓ an examination of a claim by a
different MAC than the one who made the initial determination of the
claim
Define the automated audit process Ans✓✓✓ focuses on easily
detectable payment errors and requires no human review
Define the complex audit process Ans✓✓✓ targets improper payments
that cannot be determined through a simple review and require manual
evaluation of medical records and supporting documentation to
determine a finding
Does a facility that is not a covered entity have to comply with the
Privacy or Security Rule? Ans✓✓✓ No
Fifth level of Medicare appeals Ans✓✓✓ Judicial Review in the Federal
District Court
First level of Medicare appeal Ans✓✓✓ Redetermination
Fourth level of Medicare appreal Ans✓✓✓ Appeals Counsel Review
Define abuse Ans✓✓✓ payment for items or services billed by mistake
by providers, but that Medicare should not pay, including billing for
non-covered services, misusing codes on the claim, or inappropriately
allocating costs on a cost report
Define ALJ Ans✓✓✓ Administrative Law Judge- must have at least
$160 remaining in controversy to reach this level
Define Anti-Kickback Statute Ans✓✓✓ Makes it a criminal offense to
knowingly and willfully offer, pay or solicit, or receive any remuneration
to induce or reward referrals of items or services reimbursable by a
federal healthcare program
Define fraud Ans✓✓✓ the intentional deception or misrepresentation
that an individual knows to be false and makes, knowing the deception
could result in some unauthorized benefit to himself or some other
person
Define reconsideration Ans✓✓✓ a qualified independent contractor
conducts this appeal, which consists of a panel of healthcare
professionals conducting an independent review of medical necessity
issues
Define Recovery Audit Contractors (RAC) Ans✓✓✓ Program created
through the Medicare Modernization Act to identify and recover
, improper Medicare payments paid to healthcare providers under fee-
for-service (FFS) Medicare plans
Define redetermination Ans✓✓✓ an examination of a claim by a
different MAC than the one who made the initial determination of the
claim
Define the automated audit process Ans✓✓✓ focuses on easily
detectable payment errors and requires no human review
Define the complex audit process Ans✓✓✓ targets improper payments
that cannot be determined through a simple review and require manual
evaluation of medical records and supporting documentation to
determine a finding
Does a facility that is not a covered entity have to comply with the
Privacy or Security Rule? Ans✓✓✓ No
Fifth level of Medicare appeals Ans✓✓✓ Judicial Review in the Federal
District Court
First level of Medicare appeal Ans✓✓✓ Redetermination
Fourth level of Medicare appreal Ans✓✓✓ Appeals Counsel Review
