CPMA EXAM QUESTIONS WITH
100% VERIFIED ANSWERS.
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 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 - Correct Answer-Up to $25,000
fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - Correct Answer-Anti-Kickback applies to
anyone, not just physicians; the Anti-Kickback Law requires proof of intention
and states that the person must "knowingly and willfully" violate the law.
Exclusion Statute - Correct Answer-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) - Correct Answer-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 - 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
Why should an auditor know what is in the OIG Work Plan for the current
year? - Correct Answer-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 - Correct Answer-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 - Correct Answer-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) - Correct Answer-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? - Correct Answer-50
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);
100% VERIFIED ANSWERS.
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 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 - Correct Answer-Up to $25,000
fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - Correct Answer-Anti-Kickback applies to
anyone, not just physicians; the Anti-Kickback Law requires proof of intention
and states that the person must "knowingly and willfully" violate the law.
Exclusion Statute - Correct Answer-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) - Correct Answer-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 - 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
Why should an auditor know what is in the OIG Work Plan for the current
year? - Correct Answer-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 - Correct Answer-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 - Correct Answer-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) - Correct Answer-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? - Correct Answer-50
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);
