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CPMA Exam Test Bank.Top exam Questions and answers, 100% Accurate, Verified. CMS Fraud Definition - ✔✔-Making false statements or misrepresenting facts to obtain an undeserved benefit or pa... yment 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 for 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 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 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 - ✔✔-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 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 - ✔✔-Up to $25,000 fine and/or imprisonment of up to 5 years Stark Law vs. Anti-Kickback Law - ✔✔-Anti-Kickback applies to anyone, not just physicians; the AntiKickback 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 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) - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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 - ✔✔-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) - ✔✔-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 - ✔✔-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? - ✔✔-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 - ✔✔-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 - ✔✔-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) - ✔✔-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? - ✔✔-50 Purpose of a Discovery Sample - ✔✔-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? - ✔✔-RAT-STATS What percent of precision and confidence are required to estimate the overpayment? - ✔✔-90% confidence and 25% precision level Certificate of Compliance Agreement (CCA) - ✔✔-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 - ✔✔-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 - ✔✔-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? - ✔✔-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? - ✔✔-7 Elements identified by the OIG that should be present in every compliance plan (except for individual or small group practices) - ✔✔-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 guidelines; conducting internal monitoring and auditing; and responding promptly to detected offenses and developing corrective action What should be included in the documentation of a finding of non-compliant conduct? - ✔✔-Date of incident, name of reporting party, name of the person responsible for taking action, and the follow-up action taken When was the CPG for individual and small group physician practices issued? - ✔✔-October 5, 2000 in the Federal Register What components of the compliance plan should be adopted by the practice? - ✔✔-Based on the practice's specific history with billing problems and other issues, the practice should begin by adopting only those components most likely to provide an identifiable benefit Potential benefits of a compliance program for individual and small group practices - ✔✔-Increasing accuracy of documentation; increasing the speed and optimization of proper payment of claims; minimizing billing mistakes; reducing the chances that an audit will be conducted by CMS or the OIG; and avoiding conflicts with the self-referral and anti-kickback statutes Potential risk areas for individual and small group practices indicated by the OIG in the CPG - ✔✔-Coding and billing, reasonable and necessary services, documentation, and improper inducements, kickbacks, and self-referrals Additional risk area for physicians listed in the appendix at the end of the CPG - ✔✔-Reasonable and necessary services; physician relationships with hospitals; physician billing practices; and other risk areas (rental of space in physician offices by persons or entities to which physicians refer and unlawful advertising) For which healthcare entities are CPGs listed on the OIG website? - ✔✔-Nursing facilities; hospitals; recipients of PHS research awards; pharmaceutical manufacturers; ambulance suppliers; Medicare+Choice organizations; hospices; durable medical equipment; prosthetics, orthotics, and supply industry (DMEPOS); third-party medical billing companies; clinical laboratories; and home health agencies 5 practical tips provided by CMS for creating a culture of compliance - ✔✔-Make compliance plans a priority now; know your fraud and abuse risk areas; manage your financial relationships; just because your competitor is doing something doesn't mean you can or should; and when in doubt, ask for help Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS) - ✔✔- Established in 1977 to administer the Medicare and Medicaid programs; renamed the Centers for Medicare and Medicaid Services (CMS) in 2001; largest agency within the Department of Health and Human Services; administers Medicare, Medicaid, and the Children's Health Insurance Program CMS transmittals - ✔✔-Communicate new or changed policies or procedures that will be incorporated into the CMS Online Manual System; each one has a transmittal number, an issue date, an implementation date, a Change Request number, and a subject name Medicare Learning Network (MLN) - ✔✔-Provides education, information, and resources for the healthcare professional community; offers educational products, national provider calls, provider association partnerships, provider eNews, and provider electronic mailing lists Conditions of Participation (CoP) and Conditions for Coverage (CfC) - ✔✔-Standards set forth in the Federal Register that must be met to participate in Medicare and Medicaid Programs; they include Ambulatory Surgical Centers (ASCs), Critical Access Hospitals (CAHs), and hospitals Conditions of participation for medical record services - ✔✔-The conditions include that each patient should have a medical record; medical records must be organized to allow for prompt completion, filing, and retrieval; medical records must be retained for at least 5 years; and patient confidentiality should be protected Definition from the 1995 guidelines regarding types of exam - ✔✔-The levels of E/M services are based on 4 types of examination that are defined as follows: Problem-Focused-a limited examination of the affected body area or organ system; Expanded Problem Focused-a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); Detailed-an extended examination of the affected body area(s) and other symptomatic or related organ system(s); Comprehensive-a general multi-system examination or complete examination of a single organ system Definition from the 1997 guidelines regarding general multi-system examination - ✔✔-To qualify for a given level of general multi-system examination, the following content and documentation requirements should be met: Problem Focused Examination-should include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s); Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet in one or more organ system(s) or body area(s); Detailed Examination-should include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. A detailed examination may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas; Comprehensive Examination-should include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by a bullet is expected Definition of the 1997 guidelines regarding single organ system examinations - ✔✔-Variations among these examinations in the organ systems and body areas and in the elements of the examinations reflect differing emphases among specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met: Problem Focused Examinationshould include performance and documentation of 1-5 elements identified by a bullet, whether in a box with a shaded or unshaded border; Expanded Problem Focused Examination-should include performance and documentation of at least 6 elements identified by a bullet, whether in a box with a shaded or unshaded border; Detailed Examination-examinations other than the eye and psychiatric examinations should include performance and documentation of at least 12 elements identified by a bullet, whether in a box or unshaded border. Eye and psychiatric examinations should include the performance and documentation of at least 9 elements identified by a bullet, whether in a box with a shaded or unshaded border; Comprehensive Examination-should include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. Can a provider choose from either 1995 or 1997 guidelines for each E/M service? - ✔✔-Yes Why is it important for an auditor to be familiar with both sets of guidelines? - ✔✔-A provider can choose either the 1995 or the 1997 guidelines and they must determine which will be more advantageous to the provider Purpose of the National Correct Coding Initiative (NCCI) - ✔✔-To promote correct coding methodologies and to control improper assignment of codes that results in inappropriate reimbursement; identifies Column I/Column 2 edits that are edits for code pairs that should not be billed together because one service inherently includes the other, unless an appropriate modifier is used and allowed Correct Coding Modifier (CCM) indicator - ✔✔-Determines whether a CCM causes the code pair to bypass the edit; will be either "0", "1", or "9" CCM indicator 0 - ✔✔-A CCM is not allowed and will not bypass the edits CCM indicator 1 - ✔✔-A CCM is allowed and will bypass the edits CCM indicator 9 - ✔✔-The used of modifiers is not specified; this indicator is used for all code pairs that have a deletion date that is the same as the effective date; created so that no blank spaces would be in the indicator field Medically Unlikely Edits - ✔✔-Define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT code Purpose of the medically unlikely edits - ✔✔-To help reduce the paid claims error rate for Medicare Part B claims Medicare Modernization Act - ✔✔-Required a 3-year Recovery Audit demonstration, which ran between 2005 and 2008; during the demonstration, Medicare employed Recovery Auditors to identify overpayments and underpayments made to healthcare providers and suppliers in randomly selected states Tax Relief and Healthcare Act of 2006 - ✔✔-Requires a permanent and nationwide Recovery Audit program by 2010 How many Recovery Audit Contractors does Medicare currently have? - ✔✔-4, divided by region Recovery Audit Contractors (RACs) - ✔✔-Review claims on a post-payment basis and use the same CMS regulations that providers are required to follow Fee-For-Service (FFS) Recovery Auditors - ✔✔-Contract with CMS to identify Medicare FFS improper payments; if an improper payment is identified, a review results letter is sent to the provider that includes the decision and rationale for that decision How long can FFS Recovery Auditors go back and request claims after the date the claim is paid? - ✔✔-3 years 3 types of review performed by FFS Recovery Auditors - ✔✔-Automated, semi-automated, and complex Automated review - ✔✔-no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals Semi-automated review - ✔✔-claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claim identified by data analysis as an improper payment Complex review - ✔✔-medical record required Medicare Administrative Contractor (MAC) - ✔✔-Adjusts a claim and sends a demand letter to the provider for the amount of the overpayment What happens after the provider receives the demand letter during a RAC audit? - ✔✔-If the provider agrees with the letter, he/she may submit payment; ask for a recoupment of future payments; or ask for an extended payment plan. If the provider disagrees with the demand letter, he/she may submit a discussion period request to the Recovery Auditor within 15 days from the date of the demand letter; submit a rebuttal to the MAC within 15 days from the date of the demand letter; or submit a redetermination request to the MAC within 120 days from t [Show More]

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