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CPMA |! Chapter |! 1 |! Exam |! with |!
complete |! solutions
12.1% |! - |! Correct |! answer |! ✔# |! of |! improper |! Medicare |! Fee-For-Service |! claim |! payments, |! according |! to |! Federal |! Government. FFS |! - |! Correct |! answer |! ✔Fee-For-Service Prepayment |! Review |! - |! Correct |! answer |! ✔Review |! of |! claims |! prior |! to |! payment. |! Prepayment |! reviews |! result |! in |! an |! initial |! determination. Postpayment |! Review |! - |! Correct |! answer |! ✔Review |! of |! claims |! after |! payment. |! May |! result |! in |! either |! no |! change |! to |! the |! initial |! determination |! or |! a |! revised |! determination, |! indicating |! an |! underpayment |! or |! overpayment. Underpayment |! - |! Correct |! answer |! ✔A |! payment |! a |! provider |! receives |! under |! the |! amount |! due |! for |! services |! furnished |! under |! the |! Medicare |! statute |! and |! regulations. Overpayment |! - |! Correct |! answer |! ✔A |! payment |! a |! provider |! receives |! over |! the |! amount |! due |! for |! services |! furnished |! under |! Medicare |! statutes |! and |! regulations
5 |! Common |! reasons |! for |! overpayment |! are: |! - |! Correct |! answer |! ✔*Billing |! for |! excessive |! and |! subsequent |! payment |! of |! the |! same |! service |! or |! claim. |! *Duplicate |! submission |! and |! payment |! for |! same |! service |! or |! claim *Payment |! for |! excluded |! or |! Medically |! unnecessary |! services. |! *Payment |! for |! services |! in |! setting |! not |! appropriate |! to |! pt's |! needs |! or |! condition *Payment |! to |! an |! incorrect |! payee. MACs |! - |! Correct |! answer |! ✔Medicare |! Administrative |! Contractors MAC |! Responsibilities |! - |! Correct |! answer |! ✔Process |! claims |! from |! physicians, |! hospitals, |! and |! other |! health |! care |! professionals, |! and |! submit |! payment |! to |! those |! providers |! according |! to |! Medicare |! rules |! and |! regulations |! (including |! identifying |! under- |! and |! overpayments). ZPICs |! - |! Correct |! answer |! ✔Zone |! Program |! Integrity |! Contractors PSCs |! - |! Correct |! answer |! ✔Program |! Safeguard |! Contractor ZPICs/PSCs |! - |! Correct |! answer |! ✔Perform |! investigations |! that |! are |! unique |! and |! tailored |! to |! specific |! circumstances |! and |! occur |! only |! in |! situations |! where |! there |! is |! potential |! fraud, |! and |! take |! appropriate |! corrective |! actions SMRC |! - |! Correct |! answer |! ✔Supplemental |! Medical |! Review |! Contractor
CMS |! developed |! the |! NCCI |! to |! - |! Correct |! answer |! ✔Promote |! national |! correct |! coding |! methods |! and |! to |! control |! improper |! coding |! that |! leads |! to |! inappropriate |! payment |! in |! Medicare |! Part |! B |! claims. |! NCCI |! Edits |! prevent |! improper |! payments |! when |! incorrect |! code |! combinations |! are |! reported. |! The |! NCCI |! Edits |! are |! updated |! quarterly. The |! coding |! policies |! are |! based |! on |! the |! following |! coding |! conventions... |! - |! Correct |! answer |! ✔*American |! Medical |! Association |! (AMA) |! Current |! Procedure |! Terminology |! (CPT) |! Manual *National |! and |! local |! Medicare |! policies |! and |! edits *Coding |! guidelines |! developed |! by |! the |! National |! societies, |! standard |! medical |! and |! surgical |! practice, |! and |! current |! coding |! practice. PTP |! - |! Correct |! answer |! ✔Procedure-to-Procedure |! edits Column |! One/Column |! Two |! edit |! pair |! - |! Correct |! answer |! ✔If |! a |! claim |! contains |! the |! two |! codes |! of |! an |! edit |! pair, |! the |! Column |! One |! code |! is |! eligible |! for |! payment, |! but |! CMS |! will |! deny |! the |! Column |! Two |! code NCCI |! edit |! pairs |! that |! are |! both |! appropriate |! - |! Correct |! answer |! ✔If |! both |! codes |! are |! clinically |! appropriate, |! you |! must |! append |! with |! an |! appropriate |! NCCI- associated |! modifier |! to |! be |! eligible |! for |! payment. Medicare |! beneficiaries |! and |! NCCI |! edits |! - |! Correct |! answer |! ✔You |! cannot |! bill |! Medicare |! beneficiaries |! for |! services |! denied |! based |! on |! NCCI |! Edits.
ABN |! - |! Correct |! answer |! ✔Advance |! Beneficiary |! Notice |! of |! Noncoverage ABNs |! and |! NCCI |! edits |! - |! Correct |! answer |! ✔When |! the |! denials |! are |! based |! on |! incorrect |! coding |! rather |! than |! medical |! necessity, |! you |! cannot |! use |! an |! ABNS |! (Form |! CMS-R-131) |! to |! seek |! payment |! from |! a |! Medicare |! beneficiary. NCCI |! edits |! and |! Notice |! of |! Exclusions |! from |! Medicare |! Benefits |! - |! Correct |! answer |! ✔If |! denials |! are |! based |! on |! incorrect |! coding |! rather |! than |! a |! legislated |! Medicare |! benefit |! exclusion, |! you |! cannot |! use |! a |! "Notice |! of |! Exclusions |! from |! Medicare |! Benefits" |! form |! to |! seek |! payment |! from |! a |! Medicare |! beneficiary. OCE |! - |! Correct |! answer |! ✔Outpatient |! Code |! Editor |! edits Refer |! to |! the |! OCE |! edits |! for |! claims |! - |! Correct |! answer |! ✔For |! all |! Outpatient |! institutional |! providers Refer |! to |! NCCI |! Edits |! for |! - |! Correct |! answer |! ✔Physician |! services |! under |! the |! Medicare |! Physician |! Fee |! Schedule |! (PFS) PFS |! - |! Correct |! answer |! ✔Physician |! Fee |! Schedule While |! a |! number |! of |! the |! NCCI |! Edits |! are |! included |! in |! the |! OCE |! edits |! - |! Correct |! answer |! ✔The |! OCE |! edits |! are |! not |! used |! within |! the |! Medicare |! PFS |! (Physician |! Fee |! Schedule).
Medical |! Review |! Program |! is |! performed |! by |! - |! Correct |! answer |! ✔Macs, |! ZPICs/PSCs, |! and |! SMRCs Complexity |! : |! Complex Claim |! Review |! contractors |! identify |! suspected |! improper |! billing |! through |! - |! Correct |! answer |! ✔Error |! rates |! produced |! by |! the |! CERT |! Program, |! vulnerabilities |! identified |! through |! the |! Recovery |! Audit |! Program, |! claim |! data |! analysis, |! and |! evaluation |! of |! other |! information |! (for |! example, |! complaints). Generally, |! claim |! review |! contractors |! focus |! Medical |! Review |! (MR) |! activities |! on |! identified |! - |! Correct |! answer |! ✔problem |! areas |! and |! select |! appropriate |! action |! for |! the |! severity |! of |! the |! problem. 3 |! types |! of |! corrective |! actions |! can |! result |! from |! a |! Medical |! Review |! (MR) |! - |! Correct |! answer |! ✔*Provider |! Education/Feedback *Prepayment |! review |! *Postpayment |! review. SMRC |! reviews |! are |! selected |! by |! - |! Correct |! answer |! ✔CMS Both |! Prepayment |! and |! Postpayment |! reviews |! may |! require |! - |! Correct |! answer |! ✔Providers |! to |! submit |! medical |! records
To |! help |! prevent |! improper |! payments, |! the |! MAC's |! - |! Correct |! answer |! ✔Provider |! Outreach |! and |! Education |! (POE) |! department |! educates |! providers |! submitting |! claims Prepayment |! review |! - |! Correct |! answer |! ✔Providers |! with |! identified |! problems |! may |! be |! placed |! on |! prepayment |! review, |! in |! which |! a |! selection |! of |! their |! claims |! undergo |! MR |! before |! the |! MAC |! authorizes |! payment. |! Once |! providers |! reestablish |! the |! practice |! of |! billing |! correctly, |! Prepayment |! review |! ends Postpayment |! review |! - |! Correct |! answer |! ✔Contractors |! perform |! postpayment |! claim |! reviews |! most |! commonly |! by |! using |! statistically |! valid |! sampling. |! Sampling |! allows |! estimation |! of |! an |! underpayment |! or |! overpayment |! (if |! one |! exists) |! without |! requesting |! all |! records |! on |! all |! claims |! from |! providers. CERT |! Program |! - |! Correct |! answer |! ✔Performed |! by |! CERT |! Review |! Contractor |! (RC) |! and |! CERT |! Statistical |! Contractor |! (SC) |! COMPLEXITY: |! Complex CMS |! must |! calculate |! the |! - |! Correct |! answer |! ✔National |! Medicare |! FFS |! improper |! payment |! rate. CERT |! randomly |! selects |! a |! - |! Correct |! answer |! ✔Statistically |! valid |! sample |! of |! processed |! Medicare |! FFS |! claims, |! and |! requests |! medical |! documentation |! from |! the |! provider |! or |! supplier |! that |! submitted |! the |! sampled |! claim.
Insufficient |! documentation |! - |! Correct |! answer |! ✔Submitted |! medical |! documentation |! is |! inadequate |! to |! say |! payment |! for |! the |! services |! billed; |! the |! CERT |! contractor |! reviewers |! could |! not |! conclude |! that |! the |! billed |! service |! was |! actually |! provided, |! was |! provided |! at |! the |! level |! billed |! and/or |! was |! medically |! necessary; |! or |! a |! specific |! documentation |! element |! that |! is |! required |! as |! a |! condition |! of |! payment |! is |! missing Medical |! necessity |! - |! Correct |! answer |! ✔There |! is |! adequate |! documentation |! in |! the |! medical |! records |! to |! make |! the |! informed |! decision |! that |! the |! services |! billed |! were |! Medically |! necessary |! based |! upon |! Medicare |! coverage |! and |! payment |! policies. Incorrect |! coding |! - |! Correct |! answer |! ✔Provider |! or |! supplier |! submit |! s |! medical |! documentation |! supporting |! *a |! different |! code |! than |! was |! billed *the |! service |! was |! performed |! by |! someone |! other |! than |! the |! billing |! provider |! or |! supplier *the |! billed |! service |! was |! unbundled a |! beneficiary |! was |! discharged |! to |! a |! site |! other |! than |! the |! one |! coded |! on |! a |! claim Claims |! selected |! for |! CERT |! Review |! are |! subject |! to |! potential |! - |! Correct |! answer |! ✔Postpayment |! denials, |! payment |! adjustments, |! or |! other |! actions |! depending |! upon |! the |! result |! of |! the |! review. |! Normal |! appeal |! rights |! and |! processes |! apply. CERT |! reviews |! have |! the |! following |! corrective |! actions |! - |! Correct |! answer |! ✔Improving |! system |! edits
*Increasing |! and |! focusing |! medical |! review |! on |! problem |! areas *Updating |! coverage |! policies |! and |! manuals *Conducting |! provider |! education |! efforts Recovery |! Audit |! Program |! is |! performed |! by |! - |! Correct |! answer |! ✔Medicare |! FFS |! Recovery |! Auditors Complexity |! : |! Complex Recovery |! Auditors |! - |! Correct |! answer |! ✔Review |! past |! Medicare |! FFS |! claim |! data |! for |! potential |! overpayments |! or |! underpayments, |! reviewing |! medical |! records |! when |! necessary |! to |! make |! appropriate |! determinations. Recovery |! Auditors |! follow |! - |! Correct |! answer |! ✔Medicare |! regulations, |! billing |! instructions, |! National |! Coverage |! Determinations |! (NCD), |! coverage |! provisions, |! and |! the |! respective |! Mac's |! Local |! Coverage |! Determinations |! (LCDs). Recovery |! Auditors |! do |! not |! - |! Correct |! answer |! ✔Do |! not |! develop |! or |! apply |! their |! own |! coverage, |! payment, |! or |! billing |! policies. |! In |! general, |! Recovery |! Auditors |! do |! not |! review |! a |! claim |! previously |! reviewed |! by |! another |! entity.
Postpayment |! Review |! Process: |! If |! the |! reviewer |! needs |! additional |! documentation |! - |! Correct |! answer |! ✔Will |! send |! an |! ADR. |! Provider |! must |! respond |! in |! 45 |! calendar |! days |! (30 |! days |! for |! an |! ADR |! from |! ZPIC/PSC). |! The |! reviewer |! may |! grant |! an |! extension |! at |! his/her |! discretion. |! Late |! or |! Insufficient |! documentation |! results |! in |! a |! denial. Postpayment |! Review |! Process: |! includes |! - |! Correct |! answer |! ✔CERT, |! Macs, |! Medicare |! FFS |! Recovery |! Auditors, |! SMRC, |! and |! ZPICs/PSCs Postpayment |! Review |! Process |! for |! Medicare |! FFS |! - |! Correct |! answer |! ✔Medicare |! FFS |! Recovery |! Auditors |! conduct |! automated |! reviews |! or |! may |! determine |! a |! claim |! clearly |! contains |! an |! improper |! payment |! or |! payment |! error. |! In |! this |! case, |! a |! demand |! letter |! is |! sent. Postpayment |! Review |! Process |! : |! If |! the |! reviewer |! detects |! potential |! fraud |! - |! Correct |! answer |! ✔It |! may |! refer |! the |! issue |! to |! the |! appropriate |! ZPIC |! /PSC Postpayment |! Review |! Process |! : |! If |! the |! reviewer |! receives |! all |! documentation |! timely |! - |! Correct |! answer |! ✔MAC |! will |! make |! a |! review |! determination |! and |! mail
|! a |! results |! letter |! to |! the |! provider |! within |! 60 |! days |! of |! receiving |! the |! requested |! documentation. |! Other |! reviewers |! will |! make |! and |! document |! the |! review |! determination |! and |! communicate |! results |! to |! the |! provider |! within |! 30 |! calendar |! days |! of |! receiving |! requested |! documentation. |! This |! does |! NOT |! apply |! to |! ZPICs/PSCs |! or |! CERT Postpayment |! Review |! Process: |! If |! there |! is |! an |! error |! on |! the |! claim, |! - |! Correct |! answer |! ✔The |! provider |! may |! resubmit |! a |! corrected |! claim |! if |! the |! timely |! deadline |! has |! not |! passed. |! If |! an |! overpayment |! was |! paid |! on |! the |! claim, |! the |! provider |! will |! receive |! a |! demand |! letter |! for |! the |! amount |! overpaid This |! does |! not |! apply |! to |! CERT. CERT |! and |! Postpayment |! Review |! Process: |! If |! there |! is |! an |! error |! on |! the |! claim |! - |! Correct |! answer |! ✔This |! does |! not |! apply |! to |! CERT, |! although |! CERT |! will |! accept |! additional |! documentation |! and |! signature |! attestations, |! signature |! logs, |! and |! electronic |! signature |! protocols |! received |! prior |! to |! the |! deadline |! for |! the |! annual |! report. The |! 3 |! types |! of |! business |! relationships |! that |! may |! raise |! fraud |! and |! abuse |! concerns. |! - |! Correct |! answer |! ✔Relationships |! with |! payers
The |! Federal |! False |! Claims |! Act |! (FCA) |! imposes |! - |! Correct |! answer |! ✔civil |! liability |! on |! any |! person |! who |! KNOWINGLY |! submits |! or |! CAUSES |! the |! submission |! of, |! a |! false |! or |! fraudulent |! claim |! to |! the |! Federal |! Government. The |! terms |! "knowing" |! and |! "knowingly" |! mean |! a |! person |! has |! actual |! knowledge |! of |! the |! information |! or |! acts |! in |! deliberate |! ignorance |! or |! reckless |! disregard |! of |! the |! truth, |! or |! falsity |! of |! the |! information No |! proof |! of |! specific |! intent |! to |! defraud |! is |! required |! to |! violate |! the |! Civil |! - |! Correct |! answer |! ✔False |! Claims |! Act |! (FCA) An |! example |! of |! violating |! the |! False |! Claims |! Act |! (FCA) |! may |! be |! a |! - |! Correct |! answer |! ✔a |! physician |! who |! knowingly |! submits |! claims |! to |! Medicare |! for |! medical |! services |! not |! provided. Civil |! penalties |! for |! violations |! of |! the |! False |! Claims |! Act |! (FCA), |! occurring |! on |! or |! after |! 11.25.2015, |! may |! include |! - |! Correct |! answer |! ✔fines |! of |! up |! to |! 3x |! the |! amount |! of |! damages |! sustained |! by |! the |! Government |! as |! a |! result |! of |! the |! false |! claims |! + |! up |! to |! $21,563 |! per |! false |! claim |! filed. Under |! the |! Federal |! criminal |! statutes, |! criminal |! penalties |! for |! submitting |! false |! claims |! may |! include |! - |! Correct |! answer |! ✔fines, |! imprisonment, |! or |! both. The |! Anti-Kickback |! Statute |! (AKS) |! - |! Correct |! answer |! ✔makes |! it |! a |! crime |! to |! knowingly |! and |! willfully |! offer, |! pay, |! solicit, |! or |! receive |! any |! remuneration |! directly |! or |! indirectly |! to |! induce |! or |! reward |! referrals |! of |! items |! or |! services |! reimbursable |! by |! a |! Federal |! health |! care |! program.
Remuneration |! includes |! - |! Correct |! answer |! ✔anything |! of |! value, |! such |! as |! cash, |! free |! rent, |! expensive |! hotel |! stays |! and |! meals, |! and |! excessive |! compensation |! for |! medical |! directorships |! or |! consultancies. Civil |! penalties |! for |! violating |! the |! AKS |! may |! include |! - |! Correct |! answer |! ✔penalties |! of |! up |! to |! $50,000 |! per |! kickback |! + |! 3x |! the |! amount |! of |! kickback. Criminal |! penalties |! for |! violating |! the |! AKS |! may |! include |! - |! Correct |! answer |! ✔fines, |! imprisonment, |! or |! both. The |! Physician |! Self-Referral |! Law |! (Stark |! Law) |! prohibits |! - |! Correct |! answer |! ✔a |! physician |! from |! making |! a |! referral |! for |! certain |! designated |! health |! services |! payable |! by |! Medicare |! or |! Medicaid |! to |! an |! entity |! in |! which |! the |! physician |! (or |! an |! immediate |! family |! member) |! has |! an |! ownership/investment |! interest |! or |! with |! which |! he |! or |! she |! has |! a |! compensation |! arrangement, |! unless |! an |! exception |! applies. Penalities |! for |! physicians |! who |! violate |! the |! Stark |! Law |! may |! include |! - |! Correct |! answer |! ✔fines, |! CMPs |! up |! to |! $15,000 |! for |! each |! service |! repayment |! of |! claims, |! and |! potential |! exclusion |! from |! all |! Federal |! healthcare |! programs. The |! Criminal |! Health |! Care |! Fraud |! Statute |! prohibits |! - |! Correct |! answer |! ✔knowingly |! and |! willfully |! executing, |! or |! attempting |! to |! execute, |! a |! scheme |! or |! artifice |! in |! connection |! with |! the |! delivery |! of |! or |! payment |! for |! healthcare |! benefits, |! items, |! or |! services |! to |! either.. |! |! defraud |! any |! healthcare |! benefit |! program
Provision |! of |! unnecessary |! or |! substandard |! services; Submission |! of |! false |! or |! fraudulent |! claims |! to |! a |! Federal |! health |! care |! program; Engaging |! in |! unlawful |! kickback |! arrangements; Defaulting |! on |! health |! education |! loan |! or |! scholarship |! obligation Excluded |! physicians |! may |! not |! - |! Correct |! answer |! ✔bill |! directly |! for |! treating |! Medicare |! and |! Medicaid |! patients, |! nor |! may |! their |! services |! be |! billed |! indirectly |! through |! an |! employer |! or |! a |! group |! practice. Civil |! Monetary |! Penalties |! Law |! (CMP) |! aurthorizes |! the |! imposition |! of |! CMPS |! for |! a |! variety |! of |! health |! care |! fraud |! violations. |! - |! Correct |! answer |! ✔Different |! amounts |! of |! penalties |! and |! assessments |! may |! be |! authorized |! based |! on |! the |! type |! of |! violation. |! Penalties |! range |! from |! $10,000 |! to |! $50,000/violation CMPS |! also |! may |! include |! an |! assessment |! of |! up |! to |! 3x |! the |! amount |! claimed |! for |! each |! item |! or |! service |! or |! up |! to |! 3x |! the |! amount |! of |! remuneration |! offered, |! paid, |! solicited |! or |! received. Third |! party |! payers |! include |! - |! Correct |! answer |! ✔commercial |! insurers |! and |! the |! Federal |! and |! State |! Governments. When |! the |! Federal |! Government |! covers |! items |! or |! services |! rendered |! to |! Medicare |! beneficiares |! - |! Correct |! answer |! ✔Federal |! fraud |! and |! abuse |! laws |! apply.
Many |! similar |! State |! laws |! apply |! to |! your |! provision |! of |! care |! under |! State- financed |! programs |! & |! to |! private-pay |! patients. The |! issues |! discussed |! here |! may |! apply |! to |! the |! care |! you |! provide |! to |! all |! insured |! patients. As |! a |! physician, |! payers |! trust |! you |! to |! provide |! - |! Correct |! answer |! ✔necessary cost-effective and |! quality |! care A |! physician's |! documentation |! describes |! what |! services |! they |! actually |! rendered. |! The |! Federal |! Government |! pays |! claims |! based |! soley |! - |! Correct |! answer |! ✔on |! the |! physician's |! representations |! in |! the |! claims |! documents. When |! you |! submit |! a |! claim |! for |! services |! performed |! for |! a |! Medicare |! patient, |! you |! are |! - |! Correct |! answer |! ✔filing |! a |! bill |! with |! the |! Federal |! Govt |! Certify |! you |! earned |! the |! payment |! requested complied |! with |! the |! billing |! requirements If |! a |! physician |! knows |! or |! should |! have |! known |! the |! submitted |! claim |! was |! false, |! then |! - |! Correct |! answer |! ✔the |! attempt |! to |! collect |! payment |! constitute |! a |! violation. Examples |! of |! improper |! claims |! include |! - |! Correct |! answer |! ✔Services |! you |! did |! not |! actually |! render;
