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CPMA |! Exam |! with |! verified |! detailed
|! solutions
CMS |! definition |! of |! fraud |! - |! Correct |! answer |! ✔Knowingly |! making |! false |! statements |! or |! misrepresenting |! facts |! to |! obtain |! an |! undeserved |! benefit/payment |! from |! a |! federal |! healthcare |! program. CMS |! definition |! of |! abuse |! - |! Correct |! answer |! ✔An |! action |! resulting |! in |! unnecessary |! costs |! to |! a |! federal |! healthcare |! program, |! either |! directly |! or |! indirectly Examples |! of |! fraud |! - |! Correct |! answer |! ✔* |! Billing |! supplies/services |! that |! is |! known |! as |! not |! furnished/provided
- |! Altering |! claim |! forms/receipts |! to |! receive |! a |! higher |! payment |! amount
- |! Billing |! services |! at |! a |! high |! level |! than |! provided/necessary
- |! Misrepresenting |! diagnoses |! to |! justify |! payment
- |! Making |! referrals |! for |! certain |! designated |! services |! that |! are |! prohibited Examples |! of |! abuse |! - |! Correct |! answer |! ✔* |! Misusing |! codes |! on |! a |! claim
- |! Charging |! excessively |! for |! services/supplies
- |! Billing |! services |! that |! were |! not |! medically |! necessary
- |! Failure |! to |! maintain |! adequate |! medical |! and |! financial |! records
- |! Improper |! billing |! practices
- |! Billing |! Medicare |! patients |! a |! higher |! fee |! schedule |! that |! non-Medicare |! patients Federal |! law |! that |! imposes |! liability |! on |! persons |! and |! companies |! who |! defraud |! governmental |! programs. |! Also |! known |! as |! the |! Lincoln |! Law. |! - |! Correct |! answer |! ✔False |! Claims |! Act Examples |! of |! fraud |! in |! healthcare |! 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 |! services
- |! Submitting |! claims |! for |! physician |! services |! performed |! by |! a |! non-physician |! provider |! (NPP) |! without |! regard |! to |! incident |! to |! guidelines What |! are |! the |! current |! penalties |! for |! the |! FCA? |! - |! Correct |! answer |! ✔$11,803 |! - |! $23,607 |! per |! claim When |! does |! the |! FCA |! allow |! for |! reduced |! penalties? |! - |! Correct |! answer |! ✔* |! Person |! committing |! the |! violation |! self-discloses |! and |! provides |! all |! known |! info |! within |! 30 |! days
- |! Fully |! cooperates |! with |! the |! investigation
- |! There |! is |! no |! criminal |! prosecution, |! civil |! action, |! or |! administrative |! action |! regarding |! the |! violation
What |! does |! the |! Exclusion |! Statute |! state? |! - |! Correct |! answer |! ✔A |! physician |! who |! is |! convicted |! of |! a |! criminal |! offense |! can |! be |! banned |! from |! participating |! in |! Medicare |! by |! the |! OIG. What |! is |! the |! List |! of |! Excluded |! Individuals/Entities |! (LEIE)? |! Who |! produces |! and |! updates |! this |! list? |! - |! Correct |! answer |! ✔Provides |! information |! regarding |! individuals |! and |! entities |! currently |! excluded |! from |! participation |! in |! Medicare, |! Medicaid |! and |! all |! other |! federal |! healthcare |! programs. Produced |! and |! updated |! by |! the |! OIG When |! non-compliance |! is |! identified, |! what |! does |! the |! OIG |! recommend? |! - |! Correct |! answer |! ✔* |! Take |! disciplinary |! action
- |! Document |! the |! date |! of |! the |! incident
- |! Document |! the |! name |! of |! the |! reporting |! party
- |! Document |! the |! name |! of |! person |! responsible |! for |! taking |! action
- |! Document |! follow |! up |! action |! taken A |! provider |! consistently |! charges |! a |! higher |! EM |! level |! service |! than |! is |! documented |! to |! help |! cover |! the |! cost |! of |! the |! declining |! practice. |! Is |! this |! fraud |! or |! abuse, |! why? |! - |! Correct |! answer |! ✔Fraud |! - |! The |! provider |! intentionally |! over- coded |! to |! gain |! financially. What |! does |! CoP |! stand |! for? |! - |! Correct |! answer |! ✔Conditions |! of |! Participation Which |! option |! is |! considered |! a |! material |! breach |! of |! CIA?
a.) |! Failure |! to |! engage |! and |! use |! an |! IRO |! in |! accordance |! with |! the |! CIA b.) |! Failure |! to |! hire |! an |! OIG |! employee |! to |! oversee |! compliance |! efforts c.) |! Failure |! to |! hire |! a |! full-time |! auditor |! to |! review |! every |! claim |! before |! it's |! submitted d.) |! Failure |! to |! fire |! auditors |! who |! do |! not |! agree |! with |! the |! provider's |! coding |! - |! Correct |! answer |! ✔A. |! Failure |! to |! engage |! and |! use |! an |! IRO |! in |! accordance |! with |! the |! CIA For |! 1995 |! and |! 1997 |! guidelines, |! which |! is |! used |! by |! physicians |! in |! an |! office |! setting? |! - |! Correct |! answer |! ✔They |! can |! use |! either. |! Whichever |! is |! most |! advantageous |! for |! the |! visit. What |! is |! a |! semi-automated |! review? |! - |! Correct |! answer |! ✔A |! review |! based |! on |! electronic |! data |! examined |! from |! submitted |! claims |! but |! electively |! supported |! by |! medical |! records |! sent |! by |! the |! provider. What |! can |! a |! provider |! do |! if |! they |! disagree |! with |! a |! demand |! letter |! sent |! as |! a |! result |! of |! a |! Recovery |! Audit? |! - |! Correct |! answer |! ✔Submit |! a |! discussion |! period |! request |! within |! 15 |! days |! of |! the |! date |! of |! the |! demand |! letter Recovery |! auditors |! may |! perform |! 3 |! types |! of |! reviews. |! What |! review |! requires |! medical |! records? |! - |! Correct |! answer |! ✔Independent |! Review In |! NCCI |! edits, |! what |! does |! modifier |! indicator |! zero |! (0) |! represent? |! - |! Correct |! answer |! ✔Modifiers |! are |! not |! allowed |! to |! bypass |! the |! NCCI |! edits
In |! NCCI |! edits, |! what |! does |! modifier |! indicator |! nine |! (9) |! represent? |! - |! Correct |! answer |! ✔Modifiers |! are |! not |! applicable, |! the |! NCCI |! edit |! is |! not |! in |! effect Who |! detects |! and |! prevents |! fraud, |! waste |! and |! abuse |! to |! improved |! efficiency |! of |! HHS |! programs? |! - |! Correct |! answer |! ✔Office |! of |! the |! Inspector |! General |! (OIG) What |! does |! CIA |! stand |! for? |! - |! Correct |! answer |! ✔Corporate |! Integrity |! Agreements Who |! acts |! as |! 3rd |! party |! medical |! review |! resource |! that |! provides |! objective |! and |! unbiased |! audits |! and |! reports? |! - |! Correct |! answer |! ✔Independent |! Review |! Organization |! (IRO) When |! is |! a |! mandatory |! exclusion |! implemented? |! - |! Correct |! answer |! ✔* |! Conviction |! of |! program |! related |! crimes
- |! Patient |! abuse
- |! Healthcare |! fraud When |! is |! a |! permissive |! exclusion |! implemented? |! - |! Correct |! answer |! ✔* |! Conviction |! to |! obstruction |! of |! an |! investigation |! or |! audit
- |! License |! revocation |! or |! suspicion
- |! Fraud
- |! Kickbacks What |! does |! CMP |! stand |! for? |! - |! Correct |! answer |! ✔Civil |! Monetary |! Penalties
When |! does |! the |! OIG |! seek |! CMPs? |! - |! Correct |! answer |! ✔Improper |! filing |! of |! claims What |! rights |! does |! a |! provider |! have |! if |! they |! disagree |! with |! a |! demand |! letter |! sent |! by |! the |! OIG? |! - |! Correct |! answer |! ✔They |! can |! request |! a |! hearing |! before |! the |! HHS |! Administration |! Law |! Judge |! (ALJ) How |! many |! federal |! OIGs |! are |! there? |! - |! Correct |! answer |! ✔ 73 What |! does |! the |! OIG |! oversee? |! - |! Correct |! answer |! ✔Medicare Medicaid CDC FDA National |! Institutes |! of |! Health |! (NIH) Who |! conducts/supervises |! comprehensive |! audits |! of |! HHS |! programs, |! grantees, |! and/or |! contractors |! to |! examine |! their |! performance? |! - |! Correct |! answer |! ✔Office |! of |! Audit |! Services |! (OAS) Who |! conducts |! criminal, |! civil, |! and |! administrates |! investigations |! related |! to |! fraud |! and |! misconduct |! of |! HHS |! programs, |! operations, |! and |! beneficiaries |! as |! well |! as |! operates |! the |! OIG |! hotline? |! - |! Correct |! answer |! ✔Office |! of |! Investigations |! (OI)
How |! often |! are |! the |! OIG |! Work |! Plan |! items |! updated? |! - |! Correct |! answer |! ✔Monthly What |! are |! the |! 7 |! fundamental |! elements |! of |! a |! compliance |! plan? |! - |! Correct |! answer |! ✔1. |! Implementing |! written |! policies, |! procedures, |! and |! standards |! of |! conduct
- |! Designating |! an |! officer |! and/or |! committee
- |! Conducting |! effective |! training |! and |! education
- |! Developing |! effective |! lines |! of |! communications
- |! Enforcing |! standards |! through |! guidelines
- |! Conducting |! internal |! monitoring |! and |! auditing
- |! Responding |! promptly |! to |! detect |! offenses |! and |! develop |! corrective |! action What |! does |! CMS |! stand |! for? |! - |! Correct |! answer |! ✔Centers |! for |! Medicare |! and |! Medicaid |! Services What |! 3 |! ways |! does |! CMS |! use |! to |! deliver |! information? |! - |! Correct |! answer |! ✔Transmittals |! - |! new/changed |! policies Manuals |! - |! IOMs Learning |! Network |! - |! education |! for |! providers What |! does |! CfC |! stand |! for? |! - |! Correct |! answer |! ✔Conditions |! for |! Coverage
What |! is |! a |! complex |! review |! and |! who |! performs |! it? |! - |! Correct |! answer |! ✔Occurs |! when |! a |! claim |! determination |! utilizing |! human |! review |! of |! medical |! records |! of |! other |! documentation Recovery |! auditors |! performs |! these. What |! does |! MIPS |! stand |! for? |! - |! Correct |! answer |! ✔Merit-based |! Incentive |! Payment |! Systems Provides |! a |! single |! quality |! reporting |! system |! with |! a |! single |! payment |! adjustment |! factor |! based |! on |! performance |! - |! Correct |! answer |! ✔MIPS What |! does |! AAPM |! stand |! for? |! - |! Correct |! answer |! ✔Advanced |! Alternative |! Payment |! Models Group |! of |! clinicians |! who |! came |! together |! to |! deliver |! high-quality |! care |! to |! Medicare |! patients |! - |! Correct |! answer |! ✔AAPM What |! are |! the |! 3 |! components |! of |! the |! EM |! guidelines? |! - |! Correct |! answer |! ✔History Exam Medical |! Decision |! Making |! (MDM) What |! are |! the |! 4 |! types |! of |! exams |! to |! determine |! an |! EM |! level? |! - |! Correct |! answer |! ✔Problem |! Focused Expanded |! Problem |! Focused
What |! addresses |! how |! a |! person's |! PHI |! may |! be |! used? |! - |! Correct |! answer |! ✔Privacy |! Rule Who |! are |! the |! covered |! entities |! under |! the |! Privacy |! Rule? |! - |! Correct |! answer |! ✔Health |! Plans Healthcare |! Providers Healthcare |! Clearinghouses Who |! pays |! providers |! on |! behalf |! of |! an |! individual |! receiving |! healthcare, |! dental, |! vision |! and |! prescription |! drugs? |! - |! Correct |! answer |! ✔Health |! Plans Who |! electronically |! transmits |! health |! information, |! submits |! claim |! forms, |! and |! inquires |! about |! eligibility |! benefits? |! - |! Correct |! answer |! ✔Healthcare |! Providers What |! includes |! billing |! services, |! repricing |! companies |! and |! community |! health |! management |! information |! systems |! that |! process |! non-standard |! information |! into |! standard |! information? |! - |! Correct |! answer |! ✔Healthcare |! Clearinghouses What |! does |! EDI |! stand |! for? |! - |! Correct |! answer |! ✔Electronic |! Data |! Interchange What |! do |! EDIs |! include? |! - |! Correct |! answer |! ✔Claims |! and |! encounter |! information Payments Remittance |! Advice Claim |! Status
Eligibility Enrollment/Disenrollment Referrals/Authorizations COBs Premium |! Payments What |! are |! the |! 5 |! adopted |! code |! sets? |! - |! Correct |! answer |! ✔HCPCS CPT CDT ICD9/ICD NDC True |! or |! False: |! Unique |! IDs |! for |! employers/providers |! must |! be |! on |! all |! transactions. |! - |! Correct |! answer |! ✔True Who |! performs |! functions/activities |! that |! involve |! the |! use |! or |! disclosure |! of |! health |! information |! on |! behalf |! of |! another |! person/organization, |! without |! being |! a |! member |! of |! the |! entity's |! workforce? |! - |! Correct |! answer |! ✔Business |! Associates What |! services |! can |! be |! performed |! by |! a |! Business |! Associate? |! - |! Correct |! answer |! ✔Processing |! and |! administration Data |! analysis Utilization |! review Billing
Who |! is |! responsible |! for |! criminal |! prosecutions |! under |! the |! Privacy |! Rule? |! - |! Correct |! answer |! ✔The |! Department |! of |! Justice True |! or |! False: |! Payment, |! treatment, |! or |! operations |! require |! patient |! consent |! for |! PHI. |! - |! Correct |! answer |! ✔False What |! is |! an |! example |! of |! information |! that |! can |! be |! transmitted |! electronically |! and |! covered |! under |! the |! Privacy |! Rule? |! - |! Correct |! answer |! ✔Claim |! forms What |! is |! storage |! for |! PHI |! and |! is |! kept |! for |! patient |! care? |! - |! Correct |! answer |! ✔Medical |! record When |! does |! the |! medical |! record |! start? |! - |! Correct |! answer |! ✔At |! birth Can |! you |! abbreviate |! on |! medical |! records? |! - |! Correct |! answer |! ✔Yes |! as |! long |! as |! the |! abbreviations |! are |! commonly |! recognized Who |! publishes |! a |! list |! of |! common |! abbreviates |! and |! the |! ones |! that |! shouldn't |! be |! used? |! - |! Correct |! answer |! ✔Joint |! Commission True |! or |! False: |! Statutory |! provision |! can |! be |! federal, |! state |! laws |! or |! municipal |! codes. |! - |! Correct |! answer |! ✔True
What |! are |! related |! to |! statutory |! provisions |! and |! are |! delegated |! to |! certain |! executive |! agencies |! to |! enforce |! rules |! related |! to |! medical |! records? |! - |! Correct |! answer |! ✔Regulations Guidelines |! used |! to |! establish |! the |! standard |! of |! care |! in |! negligence |! actions |! against |! healthcare |! providers |! - |! Correct |! answer |! ✔Accrediting |! Standards What |! should |! healthcare |! institutions |! do |! if |! there |! is |! an |! absence |! of |! specific |! standards/regulations |! in |! relation |! to |! medical |! records? |! - |! Correct |! answer |! ✔Establish |! their |! own |! standards/regulations |! in |! relation |! to |! the |! content |! of |! medical |! records What |! is |! the |! most |! commonly |! known |! accrediting |! organization? |! - |! Correct |! answer |! ✔Joint |! Commission Helps |! institutions |! identify |! areas |! where |! safety |! can |! be |! improved |! - |! Correct |! answer |! ✔National |! Safety |! Goals How |! should |! a |! paper |! chart |! be |! corrected? |! Can |! electronic |! charts |! be |! corrected |! the |! same |! way? |! - |! Correct |! answer |! ✔* |! Single |! strike |! through |! mistake
- |! Person |! altering |! must |! sign |! and |! date |! the |! revision
- |! Amendment
- |! Addenda Both |! paper |! and |! electronic |! charts |! can |! be |! corrected |! this |! way
What |! kind |! of |! medical |! records |! should |! efficient, |! thorough, |! and |! organized |! as |! well |! as |! signed |! before |! going |! into |! the |! patient's |! chart? |! - |! Correct |! answer |! ✔Dictated |! medical |! records What |! kind |! of |! medical |! records |! use |! check |! boxes, |! should |! have |! a |! key |! explaining |! symbols |! and |! abnormalities |! should |! be |! explained? |! - |! Correct |! answer |! ✔Template |! medical |! records What |! kind |! of |! medical |! records |! could |! have |! templates, |! are |! timeliness |! documents, |! and |! allows |! copying/cloning? |! - |! Correct |! answer |! ✔Electronic |! medical |! records What |! two |! elements |! should |! always |! be |! on |! a |! medical |! record? |! - |! Correct |! answer |! ✔Date |! and |! time True |! or |! False: |! A |! rubber |! stamp |! meets |! the |! legal |! requirement |! of |! a |! signature |! by |! CMS. |! - |! Correct |! answer |! ✔False What |! 5 |! forms |! are |! included |! in |! the |! medical |! record? |! - |! Correct |! answer |! ✔1. |! Patient |! Registration
- |! Assignment |! of |! Benefits
- |! Confirmation |! of |! Receipt |! of |! Privacy |! Notice
- |! Release |! of |! Information
- |! informed |! Consent
Part |! of |! the |! medical |! record |! that |! identifies |! the |! patient |! and |! is |! used |! to |! process |! claims, |! insurance, |! financial |! information |! and |! emergency |! contact. |! - |! Correct |! answer |! ✔Patient |! Registration Part |! of |! the |! medical |! record |! the |! patient |! has |! to |! sign |! and |! authorizes |! payment |! to |! the |! provider |! - |! Correct |! answer |! ✔Assignment |! of |! Benefits Part |! of |! the |! medical |! record |! that |! explains |! how |! the |! PHI |! will |! be |! used |! - |! Correct |! answer |! ✔Confirmation |! of |! Receipt |! of |! Privacy |! Notice Part |! of |! the |! medical |! record |! that |! states |! the |! patient |! allows |! release |! of |! medical |! records |! and |! designates |! who |! the |! medical |! information |! will |! be |! released |! to |! - |! Correct |! answer |! ✔Release |! of |! Information Part |! of |! the |! medical |! record |! that |! states |! the |! patient |! understands |! procedures, |! outcomes, |! and |! opinions. |! - |! Correct |! answer |! ✔Informed |! Consent EM: |! Description |! of |! why |! the |! patient |! is |! being |! seen |! - |! Correct |! answer |! ✔Chief |! Complaint EM: |! How |! the |! patient |! describes |! their |! symptoms |! and |! have |! prompted |! them |! to |! seek |! medical |! attention |! - |! Correct |! answer |! ✔History EM: |! Where |! assessments/observations |! are |! notated |! by |! the |! physician |! - |! Correct |! answer |! ✔Physical |! Exam
