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CMS |! Fraud |! Definition |! - |! Correct |! answer |! ✔Making |! false |! statements |! or |! misrepresenting |! facts |! to |! obtain |! an |! undeserved |! benefit |! or |! payment |! from |! a |! federal |! healthcare |! program CMS |! Abuse |! Definition |! - |! Correct |! answer |! ✔An |! action |! that |! results |! in |! unnecessary |! costs |! to |! a |! federal |! healthcare |! program, |! either |! directly |! or |! indirectly CMS |! Examples |! of |! Fraud |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! answer |! ✔$5,500-$11,000 |! per |! claim When |! does |! the |! False |! Claims |! Act |! allow |! for |! reduced |! penalties? |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! answer |! ✔Similar |! to |! the |! Stark |! Law |! but |! imposes |! more |! severe |! penalties; |! states |! that |! whoever |! knowingly |! or |! willfully |!
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 |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! 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 |! without |! regard |! to |! Incident-to |! guidelines Exceptions |! to |! the |! Stark |! Law |! - |! Correct |! 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) |! - |! Correct |! 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 |! - |! Correct |! 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
Purpose |! of |! a |! Discovery |! Sample |! - |! Correct |! 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? |! - |! Correct |! answer |! ✔RAT-STATS What |! percent |! of |! precision |! and |! confidence |! are |! required |! to |! estimate |! the |! overpayment? |! - |! Correct |! answer |! ✔90% |! confidence |! and |! 25% |! precision |! level Certificate |! of |! Compliance |! Agreement |! (CCA) |! - |! Correct |! 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 |! - |! Correct |! 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 |! - |! Correct |! 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? |! - |! Correct |! 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? |! - |! Correct |! answer |! ✔ 7 Elements |! identified |! by |! the |! OIG |! that |! should |! be |! present |! in |! every |! compliance |! plan |! (except |! for |! individual |! or |! small |! group |! practices) |! - |! Correct |! 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 |! 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? |! - |! Correct |! answer |! ✔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? |! - |! Correct |! answer |! ✔October |! 5, |! 2000 |! in |! the |! Federal |! Register What |! components |! of |! the |! compliance |! plan |! should |! be |! adopted |! by |! the |! practice? |! - |! Correct |! answer |! ✔Based |! on |! the |! practice's |! specific |! history |! with |!
5 |! practical |! tips |! provided |! by |! CMS |! for |! creating |! a |! culture |! of |! compliance |! - |! Correct |! answer |! ✔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) |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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) |! - |! Correct |! answer |! ✔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) |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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 |!
|! 1997 |! guidelines |! and |! they |! must |! determine |! which |! will |! be |! more |! advantageous |! to |! the |! provider Purpose |! of |! the |! National |! Correct |! Coding |! Initiative |! (NCCI) |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔Determines |! whether |! a |! CCM |! causes |! the |! code |! pair |! to |! bypass |! the |! edit; |! will |! be |! either |! "0", |! "1", |! or |! "9" CCM |! indicator |! 0 |! - |! Correct |! answer |! ✔A |! CCM |! is |! not |! allowed |! and |! will |! not |! bypass |! the |! edits CCM |! indicator |! 1 |! - |! Correct |! answer |! ✔A |! CCM |! is |! allowed |! and |! will |! bypass |! the |! edits CCM |! indicator |! 9 |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔To |! help |! reduce |! the |! paid |! claims |! error |! rate |! for |! Medicare |! Part |! B |! claims Medicare |! Modernization |! Act |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔Requires |! a |! permanent |! and |! nationwide |! Recovery |! Audit |! program |! by |! 2010 How |! many |! Recovery |! Audit |! Contractors |! does |! Medicare |! currently |! have? |! - |! Correct |! answer |! ✔4, |! divided |! by |! region Recovery |! Audit |! Contractors |! (RACs) |! - |! Correct |! answer |! ✔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 |! - |! Correct |! answer |! ✔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? |! - |! Correct |! answer |! ✔ 3 |! years
|! submit |! a |! redetermination |! request |! to |! the |! MAC |! within |! 120 |! days |! from |! the |! date |! of |! the |! demand |! letter |! (first |! level |! of |! appeal) CMS |! advice |! to |! prepare |! providers |! for |! RAC |! audit |! - |! Correct |! answer |! ✔Know |! where |! previous |! improper |! payments |! have |! been |! found |! and |! look |! to |! see |! what |! improper |! payments |! were |! found |! by |! the |! Recovery |! Auditors |! and |! in |! OIG |! and |! Comprehensive |! Error |! Rate |! Testing |! (CERT) |! reports; |! know |! if |! you |! are |! submitting |! claims |! with |! improper |! payments |! and |! conduct |! an |! internal |! assessment |! to |! identify |! if |! you |! are |! in |! compliance |! with |! Medicare |! rules |! and |! identify |! corrective |! actions; |! appeal |! when |! necessary |! (the |! appeal |! process |! for |! a |! Recovery |! Audit |! denial |! is |! the |! same |! as |! the |! appeal |! process |! for |! MAC |! denials) Why |! is |! it |! beneficial |! for |! an |! auditor |! to |! review |! the |! Recovery |! Auditors' |! websites |! for |! issues |! currently |! being |! reviewed? |! - |! Correct |! answer |! ✔This |! info |! can |! be |! used |! to |! target |! reviews |! to |! help |! providers |! determine |! if |! they |! are |! in |! compliance What |! changes |! will |! be |! effective |! within |! the |! next |! Recovery |! Audit |! Program |! contracts? |! - |! Correct |! answer |! ✔Recovery |! Auditors |! must |! wait |! 30 |! days |! to |! allow |! for |! a |! discussion |! before |! sending |! the |! claim |! to |! the |! MAC |! for |! adjustment |! and |! providers |! will |! not |! have |! to |! choose |! between |! initiating |! a |! discussion |! and |! an |! appeal; |! Recovery |! Auditors |! must |! confirm |! receipt |! of |! a |! discussion |! request |! within |! 3 |! days; |! Recovery |! Auditors |! must |! wait |! until |! the |! second |! level |! of |! appeal |! is |! exhausted |! before |! they |! receive |! their |! contingency |! fee; |! CMS |! is |! establishing |! revised |! ADR |! limits |! that |! will |! be |! diversified |! across |! different |! claim |! types; |! and |! CMS |! will |! require |! Recovery |! Auditors |! to |! adjust |! the |! ADR |! limits |! in |! accordance |! with |! a |! provider's |! denial |! rate. |! Providers |! with |! low |! denial |! rates |! will |! have |! lower |! ADR |! limits |! while |! providers |! with |! high |! denial |! rates |! will |! have |! higher |! ADR |! limits
Concerns |! raised |! by |! the |! Recovery |! Audit |! Program |! - |! Correct |! answer |! ✔Upon |! notification |! of |! an |! appeal |! by |! a |! provider, |! the |! Recovery |! Auditor |! is |! required |! to |! stop |! the |! discussion |! period; |! providers |! don't |! receive |! confirmation |! that |! their |! discussion |! request |! has |! been |! received; |! Recovery |! Auditors |! are |! paid |! their |! contingency |! fee |! after |! recoupment |! of |! improper |! payments, |! even |! if |! the |! provider |! chooses |! to |! appeal; |! Additional |! Documentation |! Request |! (ADR) |! limits |! are |! based |! on |! the |! entire |! facility, |! without |! regard |! to |! the |! differences |! in |! department |! within |! the |! facility; |! and |! ADR |! limits |! are |! the |! same |! for |! all |! providers |! of |! similar |! size |! and |! are |! not |! adjusted |! based |! on |! a |! provider's |! compliance |! with |! Medicare |! rules What |! is |! the |! most |! significant |! difference |! between |! the |! 1995 |! and |! 1997 |! documentation |! guidelines? |! - |! Correct |! answer |! ✔Examination You |! are |! performing |! an |! audit |! of |! evaluation |! and |! management |! services |! for |! a |! family |! practice |! office. |! In |! the |! encounter, |! you |! read |! the |! physician |! ordered |! and |! reviewed |! a |! differential |! WBC. |! Which |! of |! the |! following |! best |! describes |! what |! you |! would |! expect |! to |! see |! in |! the |! medical |! record? |! - |! Correct |! answer |! ✔Patient |! identification, |! assignment |! of |! benefits, |! patient's |! medical |! history, |! immunizations, |! physical |! examination, |! lab |! report, |! clinical |! impression, |! and |! physician |! orders. What |! is |! the |! minimum |! requirement |! for |! the |! signature |! of |! the |! author |! of |! an |! entry |! in |! the |! medical |! record? |! - |! Correct |! answer |! ✔The |! first |! initial, |! last |! name |! and |! credentials Based |! on |! JCAHO |! accreditation |! guidance |! for |! personal |! data, |! what |! two |! elements |! must |! be |! evident |! in |! the |! medical |! record: |! - |! Correct |! answer |!
A |! provider |! knows |! that |! an |! evaluation |! and |! management |! service |! they |! provide |! on |! the |! same |! date |! as |! a |! major |! procedure |! will |! be |! bundled, |! so |! submits |! the |! claim |! for |! the |! E/M |! with |! a |! different |! date |! of |! service. |! This |! is |! an |! example |! of: |! - |! Correct |! answer |! ✔Fraud What |! are |! the |! civil |! monetary |! penalties |! for |! false |! or |! fraudulent |! claims? |! - |! Correct |! answer |! ✔Up |! to |! $11,000 |! per |! claim |! and |! three |! times |! the |! amount |! improperly |! claimed Which |! type |! of |! case |! is |! not |! prosecuted |! under |! the |! federal |! false |! claims |! act? |! - |! Correct |! answer |! ✔Physician |! tax |! issues A |! full |! sample |! must |! be |! reviewed |! and |! a |! systems |! review |! must |! be |! conducted |! when |! the |! net |! financial |! error |! rate |! of |! the |! sampling |! equals |! or |! exceeds |! what |! percent? |! - |! Correct |! answer |! ✔5% What |! falls |! under |! the |! responsibility |! or |! oversight |! of |! an |! organization's |! compliance |! committee? |! - |! Correct |! answer |! ✔Regularly |! reviewing |! and |! updating |! policies |! and |! procedures, |! assisting |! with |! the |! development |! of |! standards |! of |! conduct |! and |! policies |! and |! procedures, |! and |! determining |! the |! appropriate |! strategy |! to |! promote |! compliance What |! will |! be |! one |! of |! the |! focuses |! of |! OIG |! audits |! in |! 2014? |! - |! Correct |! answer |! ✔Evaluation |! and |! Management |! New |! Patient |! Visits An |! infectious |! disease |! provider |! has |! been |! notified |! by |! the |! MAC |! (Medicare |! Administrative |! Contractor) |! in |! his |! region |! that |! their |! data |! shows |! he |! is |! billing |!
level |! 99214 |! more |! frequent |! than |! any |! other |! provider |! in |! the |! same |! specialty |! and |! same |! geographic |! region. |! The |! provider |! requests |! that |! you |! audit |! a |! sample |! of |! his |! claims |! that |! were |! coded |! as |! 99214 |! to |! determine |! if |! he |! is |! coding |! appropriately. |! What |! supporting |! references |! will |! you |! need |! to |! conduct |! the |! audit? |! - |! Correct |! answer |! ✔ 1995 |! and |! 1997 |! CMS |! Documentation |! Guidelines The |! Stark |! Statute |! applies |! to: |! - |! Correct |! answer |! ✔Only |! physicians |! who |! refer |! Medicare |! and |! Medicaid |! patients |! to |! entities |! for |! designated |! health |! care |! services |! with |! which |! the |! provider |! or |! immediate |! family |! member |! has |! a |! financial |! relationship When |! can |! a |! RAC |! extrapolate |! the |! overpayment(s) |! on |! claims? |! - |! Correct |! answer |! ✔If |! a |! RAC |! can |! demonstrate |! a |! high |! level |! of |! error, |! the |! RAC |! can |! then |! extrapolate |! the |! findings |! and |! request |! a |! refund. Example: |! Column |! 1 |! Code/Column |! 2 |! Code |! 45385/45380 |! CPT |! Code |! 45385 |! - |! Colonoscopy, |! flexible, |! proximal |! to |! splenic |! flexure; |! with |! removal |! of |! tumor(s), |! polyp(s), |! or |! other |! lesion(s) |! by |! snare |! technique |! CPT |! Code |! 45380 |! - |! Colonoscopy, |! flexible, |! proximal |! to |! splenic |! flexure; |! with |! biopsy, |! single |! or |! multiple |! Policy: |! More |! extensive |! procedure |! Modifier |! -59 |! is: |! - |! Correct |! answer |! ✔Only |! appropriate |! if |! the |! two |! procedures |! are |! performed |! on |! separate |! lesions |! or |! at |! separate |! patient |! encounters. Dr. |! Jones |! performed |! a |! femoral-femoral |! bypass |! graft |! in |! the |! morning |! on |! June |! 1, |! 20xx. |! Later |! that |! day, |! the |! graft |! clotted |! and |! the |! entire |! procedure |! was |! repeated. |! Dr. |! Jones |! was |! not |! available |! so |! Dr. |! Martin |! who |! is |! with |! a |! different |! group |! repeated |! the |! procedure |! in |! the |! evening. |! The |! auditor |! reviewed |! the |! documentation |! for |! Dr. |! Martin. |! The |! following |! was |! reported |! by |!
