CIC Exam Prep - Chapter 12 Compliance in the Facilityn Questions With Complete Solutions.

The federal ___________ law prohibits anyone (a person or corporate entity) from intentionally soliciting or receiving remuneration (anything of value such as bribes, rebates, Cash, etc.), directly or indirectly, to get Patient referrals and/or additional business reimbursed under federal healthcare Programs Such as Medicare and Medicaid. - anti-kickback The purpose of the anti-kickback rule is to protect patients and federal healthcare programs from _________ and _______ . - fraud and abuse The ___________ Law governs physician self-referral for Medicare and Medicaid patients. Also known as the "physician self-Referral law,'' this statute prohibits physicians from referring patients to medical facilities in which the physician or a member of the Physician's immediate family has a financial interest, Whether by ownership, investment, or a Compensation arrangement. It includes services billed by hospitals but provided by a Physician-Owned entity under contract with the hospital. - Stark The Recovery Audit Contractor (RAC) program was created through the Medicare Modernization Act of 2003 (MMA) to identify and _________ improper Medicare payments paid to healthcare providers under fee-for-Service (FFS) Medicare Plans. The RAC program began as a Medicare demonstration Program. - recover RACs employ two types of audit processes: __________ and ________. - automated and complex An _________ audit focuses on easily detectable payment errors. Given the ease of detectability, the automated process requires no human review or medical records to determine a finding of improper payment. - automated The ___________ audit targets improper payments that cannot be determined based on a simple review, requiring manual evaluation of medical records and supporting documentation to determine a finding. - complexCurrently, the RACs are held to a _____ -year look back period for the identification of improper payments. - 3 Providers have ________ calendar days to respond by submitting copies of the medical records to the RAC. - 45 If the provider disagrees with the RAC's determination, it may participate in the five-step Medicare Part A and Part B Administrative Appeals Process. The first level of appeal involves a __________, which is an examination of a claim by a different MAC than the one who made the initial determination on the claim. - redetermination The provider appealing the initial decision has _____ days from the date of receipt of the initial Claim determination to file an appeal. - 120