Certified Revenue Cycle Representative (CRCR) Practice Exam

Who has the legal authority to analyze provider claim documentation to ensure IPPS services were reasonable and necessary?

1. Recovery Audit Contractors (RAC)

2. The Office of the U.S. Inspector General (OIG)

3. All health plans

4. State insurance commissioners

The correct answer is: The Office of the U.S. Inspector General (OIG)

The Office of the U.S. Inspector General (OIG) has the legal authority to analyze provider claim documentation to ensure that services billed under the Inpatient Prospective Payment System (IPPS) were reasonable and necessary. The OIG is tasked with overseeing and enforcing compliance within various health programs, including Medicare and Medicaid. Their role involves conducting audits and evaluating claims data to identify improper payments, which encompasses assessing the appropriateness of services provided by healthcare entities. Recovery Audit Contractors (RAC) also review claims, but their focus is primarily on identifying overpayments and underpayments in Medicare claims, rather than having the expansive oversight authority that the OIG possesses. While all health plans may review claims for their own purposes, they do not hold the same legal authority to perform these analyses as the OIG. State insurance commissioners regulate health insurance providers at the state level, but their role does not extend to the analysis of provider claim documentation under the federal IPPS guidelines.