CPCO CHAPTER #11 EXAM QUESTIONS
WITH CORRECT ANSWERS
What does Medicare Part D cover?
Skilled Nursing
Durable Medical Equipment
Hospital
Prescription Drugs - ANSWER-Prescription Drugs
Medicare Part D is a program for prescription drug plans
What is the level 3 of the RAC Claims appeals process?
Redetermination by a MAC
Reconsideration by a Qualified Improvement Contractor (QIC)
Hearing by an Administrative Law Judge (ALJ)
Review by the Medicare Appeals Council within the Departmental Appeals Board -
ANSWER-Hearing by an Administrative Law Judge (ALJ)
Level three of claims appeals is a Hearing by an Administrative Law Judge ALJ
RACs perform what type of review(s)
Automated
Prospective
Complex
Automated and complex - ANSWER-Automated and complex
There are two types of reviews: Automated (no medical record needed) and Complex
(medical record required).
Audit MICs can audit a Medicaid provider throughout his or her__________.
city
county
country
state - ANSWER-country
An Audit MIC can audit a Medicaid provider throughout the country.
The Yates Memo of 2015 considers what factors?
Physician wrongdoing
Corporate wrongdoing
Global fraud
International fraud - ANSWER-Corporate wrongdoing
The 2015 Yates Memo addresses corporate wrongdoing and holds administrators
accountable as well as providers. More information can be found at:
https://www.justice.gov/dag/file/769036/download. The Yates Memo could have a
significant effect on healthcare companies and their executives for being held
accountable for healthcare fraud.
, Which statement is TRUE regarding ADR limits for RAC audits.
Up to 50 medical records per provider can be requested every 45 days in a group of 25-
49 providers.
Facilities have a baseline annual ADR, and, after three consecutive 45 day ADR cycles,
the facility receives an adjusted ADR based on the denial rate for the next three
consecutive 45 day ADR cycles.
Solo Chiropractors can have up to 25 medical records requested every 45 days.
Up to 25% of all claims submitted by DME providers can be requested every 45 days. -
ANSWER-Facilities have a baseline annual ADR, and, after three consecutive 45 day
ADR cycles, the facility receives an adjusted ADR based on the denial rate for the next
three consecutive 45 day ADR cycles.
Summary of RAC Medical Record Limits:• Institutional Providers (Facilities)o The
baseline annual ADR Limit is one-half of one percent (0.5%) of the provider's total
number of paid Medicare claims from a previous 12-month period. o After three (3) 45-
day ADR cycles, CMS will calculate (or recalculate) a provider's Denial Rate, which
reflects their compliance with Medicare rules. The Denial Rate will be calculated using
the number of claims containing improper payments that resulted in overpayments (less
any determinations that are fully overturned during appeal) divided by the total number
of reviewed claims, expressed as a percentage, on a cumulative basis. The Denial Rate
will then be used to identify a provider's corresponding "Adjusted" ADR Limit. The
Adjusted ADR Limit will be used for the next three (3) 45-day ADR cycles.• Physicians
(including podiatrists, chiropractors)o Less than 5 providers: 10 medical records per 45
days per NPIo 6-24 providers: 25 medical records per 45 days per NPIo 25-49
providers: 40 medical records per 45 days per NPI• 50 or more providers: 50 medical
records per 45 days per NPIDMEo 10% of all claims submitted for the previous full
calendar year, divided into eight periods (45 days)
Which of these statements are not true about ZPICs?
Initiates appropriate administrative actions to deny or to suspend payments that should
not be made to providers where there is reliable evidence of fraud
Investigates (determines the factual basis of) allegations of fraud made by beneficiaries,
providers, CMS, OIG, and other sources
Proactively identifies incidents of potential fraud that exist outside of its service area
Refers cases to the Office of the Inspector General/Office of Investigations for
consideration of civil and criminal prosecution and/or application of administrative
sanctions - ANSWER-Proactively identifies incidents of potential fraud that exist outside
of its service area
ZPICs do not proactively identify incidents of potential fraud that exist within its service
area, nor take appropriate action on each case.
The cornerstone of the MACs' efforts to prevent improper payments is that each
contractor's Error Rate Reduction Plan falls into three categories. Which item below is
NOT one of the categories?
Targeted provider education to items or services with the highest improper payments.
WITH CORRECT ANSWERS
What does Medicare Part D cover?
Skilled Nursing
Durable Medical Equipment
Hospital
Prescription Drugs - ANSWER-Prescription Drugs
Medicare Part D is a program for prescription drug plans
What is the level 3 of the RAC Claims appeals process?
Redetermination by a MAC
Reconsideration by a Qualified Improvement Contractor (QIC)
Hearing by an Administrative Law Judge (ALJ)
Review by the Medicare Appeals Council within the Departmental Appeals Board -
ANSWER-Hearing by an Administrative Law Judge (ALJ)
Level three of claims appeals is a Hearing by an Administrative Law Judge ALJ
RACs perform what type of review(s)
Automated
Prospective
Complex
Automated and complex - ANSWER-Automated and complex
There are two types of reviews: Automated (no medical record needed) and Complex
(medical record required).
Audit MICs can audit a Medicaid provider throughout his or her__________.
city
county
country
state - ANSWER-country
An Audit MIC can audit a Medicaid provider throughout the country.
The Yates Memo of 2015 considers what factors?
Physician wrongdoing
Corporate wrongdoing
Global fraud
International fraud - ANSWER-Corporate wrongdoing
The 2015 Yates Memo addresses corporate wrongdoing and holds administrators
accountable as well as providers. More information can be found at:
https://www.justice.gov/dag/file/769036/download. The Yates Memo could have a
significant effect on healthcare companies and their executives for being held
accountable for healthcare fraud.
, Which statement is TRUE regarding ADR limits for RAC audits.
Up to 50 medical records per provider can be requested every 45 days in a group of 25-
49 providers.
Facilities have a baseline annual ADR, and, after three consecutive 45 day ADR cycles,
the facility receives an adjusted ADR based on the denial rate for the next three
consecutive 45 day ADR cycles.
Solo Chiropractors can have up to 25 medical records requested every 45 days.
Up to 25% of all claims submitted by DME providers can be requested every 45 days. -
ANSWER-Facilities have a baseline annual ADR, and, after three consecutive 45 day
ADR cycles, the facility receives an adjusted ADR based on the denial rate for the next
three consecutive 45 day ADR cycles.
Summary of RAC Medical Record Limits:• Institutional Providers (Facilities)o The
baseline annual ADR Limit is one-half of one percent (0.5%) of the provider's total
number of paid Medicare claims from a previous 12-month period. o After three (3) 45-
day ADR cycles, CMS will calculate (or recalculate) a provider's Denial Rate, which
reflects their compliance with Medicare rules. The Denial Rate will be calculated using
the number of claims containing improper payments that resulted in overpayments (less
any determinations that are fully overturned during appeal) divided by the total number
of reviewed claims, expressed as a percentage, on a cumulative basis. The Denial Rate
will then be used to identify a provider's corresponding "Adjusted" ADR Limit. The
Adjusted ADR Limit will be used for the next three (3) 45-day ADR cycles.• Physicians
(including podiatrists, chiropractors)o Less than 5 providers: 10 medical records per 45
days per NPIo 6-24 providers: 25 medical records per 45 days per NPIo 25-49
providers: 40 medical records per 45 days per NPI• 50 or more providers: 50 medical
records per 45 days per NPIDMEo 10% of all claims submitted for the previous full
calendar year, divided into eight periods (45 days)
Which of these statements are not true about ZPICs?
Initiates appropriate administrative actions to deny or to suspend payments that should
not be made to providers where there is reliable evidence of fraud
Investigates (determines the factual basis of) allegations of fraud made by beneficiaries,
providers, CMS, OIG, and other sources
Proactively identifies incidents of potential fraud that exist outside of its service area
Refers cases to the Office of the Inspector General/Office of Investigations for
consideration of civil and criminal prosecution and/or application of administrative
sanctions - ANSWER-Proactively identifies incidents of potential fraud that exist outside
of its service area
ZPICs do not proactively identify incidents of potential fraud that exist within its service
area, nor take appropriate action on each case.
The cornerstone of the MACs' efforts to prevent improper payments is that each
contractor's Error Rate Reduction Plan falls into three categories. Which item below is
NOT one of the categories?
Targeted provider education to items or services with the highest improper payments.
