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CPMA Exam Complete Questions And Answers With Latest Quiz
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CPMA Exam Complete Questions And Answers With Latest Quiz CPMA Exam Complete Questions And Answers With Latest Quiz
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CPMA Exam Complete Questions And Answers With Latest Quiz CMS Fraud Definition Correct Answer: Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Abuse Definition Correct Answer: An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Examples of Fraud Correct Answer: Billing for services and/or supplies that you know were not furnished or provided, altering claim forms and/or receipts to receive a higher payment amount, billing a Medicare patient above the allowed amount for servic es, billing for services at a higher level than provided or necessary, misrepresenting the diagnosis to justify payment CMS Examples of Abuse Correct Answer: Misusing codes on a claim, charging excessively for services or supplies, billing for services that were not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, b illing Medicare patients a higher fee schedule than non -Medicare patients False Claims Act Correct Answer: Any person is liable if they knowingly present or cause to be presented a false or fraudulent claim for payment or approval; knowingly makes, uses, or causes to be made or used, a false record or material to a false or fraudulent claims Current False Claims Act penalties Correct Answer: $5,500 -$11,000 per claim When does the False Claims Act allow for reduced penalties? Correct Answer: If the person committing the violation self -discloses and provides all known info within 30 days, fully cooperates with the investigation, and there is no criminal prosecution, civ il action, or administrative action regarding the violation Qui Tam or "Whistleblower" provision Correct Answer: If an individual (known as a "relator") knows of a violation of the False Claims Act, he or she may bring a civil action on behalf of him or herself and on behalf of the U.S. government; the relator may be awarded 15 -25% of the dollar amount recovered Stark or Physician Self -Referral Law Correct Answer: Bans physicians from referring patients for certain services to entities in which the physician or an immediate family member has a direct or indirect financial relationship; bans the entity from billing Medicare or Medicaid for the services provided as a result of the self -referral Anti-Kickback Law Correct Answer: Similar to the Stark Law but imposes more severe penalties; states that whoever knowingly or willfully solicits or receives any remuneration in return for referring an individual to a person for the furnishing or arranging of any item or service for which payment may be made in whole or in part under a federal healthcare program or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a federal healthcare program is guilty of a felony Penalty for violating the Anti -Kickback Law Correct Answer: Up to $25,000 fine and/or imprisonment of up to 5 years Stark Law vs. Anti -Kickback Law Correct Answer: Anti -Kickback applies to anyone, not just physicians; the Anti -Kickback Law requires proof of intention and states that the person must "knowingly and willfully" violate the law. Exclusion Statute Correct Answer: Under the Exclusion Statute, a physician who is convicted of a criminal offense —such as Medicare fraud (both misdemeanor and felony convictions), patient abuse and neglect, or illegal distribution of controlled substances —can be banned from participating in Medicare by the OIG. Physicians who are excluded may not directly or indirectly bill the federal government for the services they provide to Medicare patients. List of Excluded Individuals/Entities (LEIE) Correct Answer: Produced and updated by the OIG; provides information regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all other federal healthcare programs; so rts excluded individuals or entities by the legal basis for the exclusion, the types of individuals and entities that have been excluded, and the states where the excluded individual resided at the time they were excluded or the state in which the entity w as doing business Civil Monetary Penalties Law Correct Answer: The Social Security Act authorizes the HHS to seek civil monetary penalties and exclusion for certain behaviors. These penalties are enforced by the OIG through the Civil Monetary Penalties (CMP) Law. The severi ty of penalties and monetary amounts charged depend on the type of conduct engaged in by the physician. A physician can incur a CMP in the following ways: Presenting or causing claims to be presented to a federal healthcare program that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent.Violating the Anti -Kickback Statute by knowingly and willfully (1) offering or paying remuneration to induce the referral of federal healthcare program busine ss, or (2) soliciting or receiving remuneration in return for the referral of federal healthcare program business. Knowingly presenting or causing claims to be presented for a service for which payment may not be made under the Stark law Amount of civil monetary penalties Correct Answer: Range from $10,000 -$50,000 per violation and an assessment of up to 3 times the amount of the over -payments Reverse False Claims section of the False Claims Act Correct Answer: Final section that provides liability where a person acts improperly to avoid paying money owed to the government Examples of fraud/misconduct subject to the False Claims Act Correct Answer: Falsifying a medical chart notation; submitting claims for services not performed, not requested, or unnecessary; submitting claims for expired drugs; upcoding and/or unbundling s ervices; submitting claims for physician services performed by a non -
physician provider without regard to Incident -to guidelines Exceptions to the Stark Law Correct Answer: General exceptions to both ownership and compensation arrangement prohibitions (in -office ancillary services); general exceptions related only to ownership or investment prohibition for ownership in publicly trad ed securities and mutual funds (services furnished by a rural provider); exceptions related to other compensation arrangements (personal services arrangements and rental of office space and equipment) Office of the Inspector General (OIG) Correct Answer: Detects and prevents fraud, waste, and abuse and improves efficiency of HHS programs; most resources are directed toward the oversight of Medicare and Medicaid, but also extend to the Centers for Diseas e Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and Drug Administration (FDA) OIG Work Plan Correct Answer: Published annually; lists the various projects that will be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspect or General; summarizes new and ongoing reviews and activities that OIG plans to pursue during the next fiscal year and beyond Why should an auditor know what is in the OIG Work Plan for the current year? Correct Answer: It allows an auditor to inform providers and facilities of services or issues of which to be especially mindful in the coming year; may be helpful in forming the scope of an audit for a provider or facility or may influence recommendations given to a practice Corporate Integrity Agreements Correct Answer: Required by the OIG s a condition of not seeking exclusion from participation when an individual or entity seeks to settle civil healthcare fraud cases; typically last 5 yrs but can be longer; most have the sa me core requirements along with specific steps for the individual or entity that are related to the conduct that led to the settlement Core requirements in CIAs Correct Answer: Hiring a compliance officer/appointing a compliance committee; developing written standards and policies; implementing a comprehensive employee training program; retaining an independent review organization (IRO) t o conduct annual reviews; establishing a confidential disclosure program; restricting employment of ineligible persons; reporting overpayments, reportable events, and ongoing investigations/legal proceedings; providing an implementation report and annual reports to the OIG on the status of the entity's compliance activities Independent review organization (IRO) Correct Answer: Acts as a 3rd party medical review resource that provides objective, unbiased audits and reports How many sampling units are selected for review in a Discovery Sample under a CIA? Correct Answer: 50 Purpose of a Discovery Sample Correct Answer: Used to determine the net financial error rate; if the error rate exceeds 5%, a Full Sample must be reviewed, along with a Systems Review What is the name of the statistical sampling program provided by the OIG to randomly select and determine the size of the Discovery Sample? Correct Answer: RAT -STATS What percent of precision and confidence are required to estimate the overpayment? Correct Answer: 90% confidence and 25% precision level Certificate of Compliance Agreement (CCA) Correct Answer: Require the provider to certify that is will continue to operate its existing compliance programs and to report to OIG for a lesser period of time (usually 3 years); introduced in Inspector General Janet Rehnquist's An Open Letter to Healthcare Providers in November 2011 Compliance Plan Correct Answer: Represents comprehensive documentation that a provider, practice, facility, or other healthcare entity is taking steps to adhere to the federal and state laws that affect it Voluntary compliance plan guidance (CPG) documents Correct Answer: Developed by the OIG for a variety of healthcare settings; indicate the comprehensive framework, standards, and principles by which an effective internal compliance program may be establish ed and maintained Are compliance plans mandatory? Correct Answer: No, they are currently voluntary. The Affordable Care Act makes compliance programs mandatory for providers and other healthcare providers but there is not yet an implementation date How many elements has the OIG identified that should be present in every compliance plan? Correct Answer: 7 Elements identified by the OIG that should be present in every compliance plan (except for individual or small group practices) Correct Answer: Implementing written policies, procedures and standards of conduct; designating a compliance officer and/or comp liance committee; conducting effective training and education; developing effective lines of communication; enforcing standards through well -publicized disciplinary
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