CPMA STUDY QUESTIONS & Answers, (accurate). Rated A+

CPMA STUDY QUESTIONS & Answers, (accurate). Rated A+ WHAT IS THE IMPORTANCE OF AUDIT IN A PRACTICE? - -1. Reviewing quality of care provided to patients. 2. Educating providers on documentation. 3. Ensuring all services are supported and all appropriate revenue is captured. 4. Defending against external audit malpractice litigation and health plan request and denial. Exclusion Statute - -1.Physician is banned from participating in any federal or state healthcare program by OIG 2. They can't bill federal or state for any services provided .3 length: host less than five years .4 When exclusionary period has ended dr must apply for reinstatement and receive authorize notice from OIG that reinstate has been granted Abuse - -In action resulting in unnecessary cost to a federal healthcare program either directly or indirectly What is the civil penalty - -Not less than 5000 and not more than 10,000 per claim x3 times the amount of government damages Federal False Claims Act - -Having knowledge that claims is fake. .1 knowing and knowingly that a person must act in deliberate ignorance of the truth or falsely of the relevant information or act in a reckless manner of the truth or falsity of the Information Qui Tam - -whistleblower what percentage is offered for a whistleblower/qui tam as an award from what is recovered by the government? - -between 15% and 25% fraud - -Knowingly making false statements or misrepresenting facts to obtain an undeserved benefit or payment from federal healthcare program Discovery sample - -CIA - 50 samples units randomly selected *determines the net financial error rate .2 if error rate exceeds 5% a full sample must be reviewed HHS OIG 3 core publications - - plan nnual report to congress 3. compendium unimplemented recommendation non-compliant conduct must be documented in compliance files & should include - -1. date of incident of the reporting party of the person responsible for taking action follow up the action taken What is an auditor - -Reviews healthcare providers policies add procedures to ensure compliance with applicable requirements cms uses what avenues to deliver Information - -sts 2. transmitting ls medicare learning network CIA Corporate Integrity Agreement - -Last five years can be longer if OIG likes OIG will require CIA as a condition for not seeking exclusion from participation when they seek to settle civil fraud cases requirements hearing compliance officer/ appointments compliance committee , employee training program,IRO (IRO) independent review organization - -(Third-party medical review resource) 1. Provides objective unbiased audits and reports. 2. OIG can notify provider within 30 days if IRO is unacceptable and may request IRO be terminated and another IRO be retained. Civil Monetary Penalties Law (CMP) - -(Improper filing of claims- Upcoding, miscoding) 1. Knowing it's a false claim. 2. Knowing Dr. is not licensed. 3. Changing DOS to when PT was effective with a government plan. 4. Knowing it's not medically necessary. *Penalties 10,000 to 50,000 per violation up to $22,363 for each item/service and 3X the amount improperly claimed. If disagree* can request hearing before an HHS administrative law judge. Anti-Kickback Law - -(Applies to anyone not just physicians) receiving cash or payment knowingly that it is illegal for referring people to doctor's office. *intent must be proven* $25,00 per violation - up to 5 years in prison (OIG) Office of Inspector General responsibilities - -To detect and prevent fraud, waste, abuse and violations of law, and to promote economy, efficiency and effectiveness in the operations of the federal government. (MUEs) medically unlikely edits - -Defined the maximum units of service that a provider would report under most circumstances for single beneficiary on a single date of service for a specific HCPCS/CPT code. (NCI) National correct coding initiative - -Implemented to promote correct coding methodologies and to control and improper assignments of codes that resulted in inappropriate reimbursement. Compliance plan - -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. What happens if a (FFS RAC) fee for service recovery auditor identifies improper payment? - -Review results letter is sent to provider that includes decision and rationale. MAC will adjust claim and send a demand letter to provider for amount of overpayment. If provider agrees, they may submit payment or ask for a payment plan.*If they disagree - within 30 days submit a discussion.*Cement a rebuttal to MAC within 15 days or submit redetermination to MAC within 120 days.*Last option is first level of appeal. MAC equals Medicare administrative contractor.