HCQM - Regulatory Environment Exam
2025 Questions and Answers
Medicare Part A - ANSWER-Pays for inpatient hospital, SNF, HH related to
hospital stay, and hospice care. Financing comes from a 2.9% payroll tax split
between employers and employees.
Medicare Part B - ANSWER-Pays for physician, outpatient hospital, ESRD, lab,
DME, and some HH. Coverage is voluntary - about 92% of beneficiaries are
enrolled. 25% is covered by beneficiary premiums/75% other government
revenues
Medicare Part C - ANSWER-Medicare Advantage Program - typically private
managed care companies are paid capitation by the government to provide all Part
A, B, & D services.
Medicare Part D - ANSWER-standard rx benefit. Beneficiaries are responsible for
a portion of the cost which varies on brand vs. generic and how much money they
have already spent on rx that year.
Elliot Fisher - ANSWER-Introduced the Accountable Care Organization and
incorporated it into Medicare Shared Savings Program provisions of the PPACA.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1
, Accountable Care Organization - ANSWER-Advocates for coordination of health
services by organizations with an intention to promote an integrated approach to
health care with efficiency and cost savings.
State Scope of Practice Restriction - ANSWER-intended to ensure that
professionals offer services according to their skill and training.
Stark Law - ANSWER-Prohibits physicians from referring patients for designated
health services where there is a financial relationship between the providers. CMS
publishes a list of CPT codes on an annual basis that identify DHS services.
Federal Anti-Kickback Statute - ANSWER-Prohibits providing remuneration or
giving of value with the intent of inducing referrals. Includes both criminal and
civil penalties.
The Federal Health Care False Claims - ANSWER-May not knowingly submit a
false claim for payment - includes actual knowledge or deliberate disregard such as
when bills were submitted that would be paid for services not rendered
Qui Tam Actions - ANSWER-Part of the False Claims Act - allows a "relator" to
bring a suit on behalf of the government after filing an action under seal. The
government will review the act and choose whether to intervene (join the suit).
Individuals may continue without the government joining if they desire. Relators
will get between 15-30% of the recovery depending on whether the government
joined the case.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
2025 Questions and Answers
Medicare Part A - ANSWER-Pays for inpatient hospital, SNF, HH related to
hospital stay, and hospice care. Financing comes from a 2.9% payroll tax split
between employers and employees.
Medicare Part B - ANSWER-Pays for physician, outpatient hospital, ESRD, lab,
DME, and some HH. Coverage is voluntary - about 92% of beneficiaries are
enrolled. 25% is covered by beneficiary premiums/75% other government
revenues
Medicare Part C - ANSWER-Medicare Advantage Program - typically private
managed care companies are paid capitation by the government to provide all Part
A, B, & D services.
Medicare Part D - ANSWER-standard rx benefit. Beneficiaries are responsible for
a portion of the cost which varies on brand vs. generic and how much money they
have already spent on rx that year.
Elliot Fisher - ANSWER-Introduced the Accountable Care Organization and
incorporated it into Medicare Shared Savings Program provisions of the PPACA.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1
, Accountable Care Organization - ANSWER-Advocates for coordination of health
services by organizations with an intention to promote an integrated approach to
health care with efficiency and cost savings.
State Scope of Practice Restriction - ANSWER-intended to ensure that
professionals offer services according to their skill and training.
Stark Law - ANSWER-Prohibits physicians from referring patients for designated
health services where there is a financial relationship between the providers. CMS
publishes a list of CPT codes on an annual basis that identify DHS services.
Federal Anti-Kickback Statute - ANSWER-Prohibits providing remuneration or
giving of value with the intent of inducing referrals. Includes both criminal and
civil penalties.
The Federal Health Care False Claims - ANSWER-May not knowingly submit a
false claim for payment - includes actual knowledge or deliberate disregard such as
when bills were submitted that would be paid for services not rendered
Qui Tam Actions - ANSWER-Part of the False Claims Act - allows a "relator" to
bring a suit on behalf of the government after filing an action under seal. The
government will review the act and choose whether to intervene (join the suit).
Individuals may continue without the government joining if they desire. Relators
will get between 15-30% of the recovery depending on whether the government
joined the case.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
