CPMA Exam Questions and Correct Answers | Latest Update
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Course
CPMA
Institution
CPMA
CMS Fraud Definition
Making false statements or misrepresenting facts to obtain an undeserved
benefit or payment from a federal healthcare program
CMS Abuse Definition
An action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
CMS Exam...
Making false statements or misrepresenting facts to obtain an undeserved
benefit or payment from a federal healthcare program
CMS Abuse Definition
An action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
CMS Examples of Fraud
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 fo r
services, billing for services at a higher level than provided or necessary,
misrepresenting the diagnosis to justify payment
CMS Examples of Abuse
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, billing
Medicare patients a higher fee schedule than non -Medicare patients
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, Best Grades | Must Pass | Latest Update | Correct Answers | 2024/ 2025
False Claims Act
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
$5,500-$11,000 per claim
When does the False Claims Act allow for reduced penalties?
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, civil action, or administrative action regarding the
violation
Qui Tam or "Whistleblower" provision
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 h erself
and on behalf of the U.S. government; the relator may be awarded 15 -
25% of the dollar amount recovered
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, Best Grades | Must Pass | Latest Update | Correct Answers | 2024/ 2025
Stark or Physician Self-Referral Law
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
Similar to the Stark Law but imposes more sev ere 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 healthcar e program is guilty of a
felony
Penalty for violating the Anti-Kickback Law
Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law
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, Best Grades | Must Pass | Latest Update | Correct Answers | 2024/ 2025
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
Under the Exclusion Statute, a physician w ho 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)
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; sorts excluded
individuals or entities by the legal basis for the exclusion, the types of
individuals and entities that have been excluded, and t he states where the
excluded individual resided at the time they were excluded or the state in
which the entity was doing business
Civil Monetary Penalties Law
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