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CPMA STUDY GUIDE EXAM QUESTIONS WITH CORRECT ANSWERS
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CPMA STUDY GUIDE EXAM QUESTIONS WITH CORRECT ANSWERS
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CPMA STUDY GUIDE EXAM QUESTIONSWITH CORRECT ANSWERS
CMS Fraud Definition - Answer-Making false statements or misrepresenting facts to
obtain an undeserved benefit or payment from a federal healthcare program
CMS Abuse Definition - Answer-An action that results in unnecessary costs to a federal
healthcare program, either directly or indirectly
CMS Examples of Fraud - 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 services,
billing for services at a higher level than provided or necessary, misrepresenting the
diagnosis to justify payment
CMS Examples of Abuse - 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, billing
Medicare patients a higher fee schedule than non-Medicare patients
False Claims Act - 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 - Answer-$5,500-$11,000 per claim
When does the False Claims Act allow for reduced penalties? - 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, civil action, or
administrative action regarding the violation
Qui Tam or "Whistleblower" provision - 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 - 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 - 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 - Answer-Up to $25,000 fine and/or
imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - 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 - 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) - 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; sorts
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 was
doing business
Civil Monetary Penalties Law - 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 severity 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 business, 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 - 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 - 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 - 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 services;
submitting claims for physician services performed by a non-physician provider without
regard to Incident-to guidelines
Exceptions to the Stark Law - 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 traded
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) - 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 Disease
Control and Prevention (CDC), National Institutes of Health (NIH), and the Food and
Drug Administration (FDA)
OIG Work Plan - 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 Inspector
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? -
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 - 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 same 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 - 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) to 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) - 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? -
Answer-50
Purpose of a Discovery Sample - 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? - Answer-RAT-STATS
What percent of precision and confidence are required to estimate the overpayment? -
Answer-90% confidence and 25% precision level
Certificate of Compliance Agreement (CCA) - 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 - 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 - 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 established
and maintained
Are compliance plans mandatory? - 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? - Answer-7
Elements identified by the OIG that should be present in every compliance plan (except
for individual or small group practices) - Answer-Implementing written policies,
procedures and standards of conduct; designating a compliance officer and/or
compliance committee; conducting effective training and education; developing effective
lines of communication; enforcing standards through well-publicized disciplinary
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