CPMA Exam| Ques ons and answers | Updated RATED
A+ NEW EDITION
CMS Fraud Defini on
Making false statements or misrepresen ng facts to obtain an undeserved benefit or payment
from a federal healthcare program
CMS Abuse Defini on
An ac on that results in unnecessary costs to a federal healthcare program, either directly or
indirectly
CMS Examples of Fraud
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 pa ent above the
allowed amount for services, billing for services at a higher level than provided or necessary,
misrepresen ng the diagnosis to jus fy payment
CMS Examples of Abuse
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 prac ces, billing Medicare pa ents a higher fee schedule than non-Medicare
pa ents
False Claims Act
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 penal es
$5,500-$11,000 per claim
When does the False Claims Act allow for reduced penal es?
If the person commi0ng the viola on self-discloses and provides all known info within 30 days,
fully cooperates with the inves ga on, and there is no criminal prosecu on, civil ac on, or
administra ve ac on regarding the viola on
,Qui Tam or "Whistleblower" provision
If an individual (known as a "relator") knows of a viola on of the False Claims Act, he or she may
bring a civil ac on 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
Bans physicians from referring pa ents for certain services to en es in which the physician or
an immediate family member has a direct or indirect financial rela onship; bans the en ty from
billing Medicare or Medicaid for the services provided as a result of the self-referral
An -Kickback Law
Similar to the Stark Law but imposes more severe penal es; states that whoever knowingly or
willfully solicits or receives any remunera on 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 viola ng the An -Kickback Law
Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. An -Kickback Law
An -Kickback applies to anyone, not just physicians; the An -Kickback Law requires proof of
inten on and states that the person must "knowingly and willfully" violate the law.
Exclusion Statute
Under the Exclusion Statute, a physician who is convicted of a criminal offense—such as
Medicare fraud (both misdemeanor and felony convic ons), pa ent abuse and neglect, or illegal
distribu on of controlled substances—can be banned from par cipa ng 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 pa ents.
List of Excluded Individuals/En es (LEIE)
Produced and updated by the OIG; provides informa on regarding individuals and en es
currently excluded from par cipa on in Medicare, Medicaid, and all other federal healthcare
programs; sorts excluded individuals or en es by the legal basis for the exclusion, the types of
,individuals and en es that have been excluded, and the states where the excluded individual
resided at the me they were excluded or the state in which the en ty was doing business
Civil Monetary Penal es Law
The Social Security Act authorizes the HHS to seek civil monetary penal es and exclusion for
certain behaviors. These penal es are enforced by the OIG through the Civil Monetary Penal es
(CMP) Law. The severity of penal es 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:
Presen ng 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.Viola ng the An -Kickback Statute by knowingly and willfully (1) offering or paying
remunera on to induce the referral of federal healthcare program business, or (2) solici ng or
receiving remunera on in return for the referral of federal healthcare program business.
Knowingly presen ng or causing claims to be presented for a service for which payment may
not be made under the Stark law
Amount of civil monetary penal es
Range from $10,000-$50,000 per viola on and an assessment of up to 3 mes the amount of
the over-payments
Reverse False Claims sec on of the False Claims Act
Final sec on 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
Falsifying a medical chart nota on; submi0ng claims for services not performed, not requested,
or unnecessary; submi0ng claims for expired drugs; upcoding and/or unbundling services;
submi0ng claims for physician services performed by a non-physician provider without regard
to Incident-to guidelines
Excep ons to the Stark Law
General excep ons to both ownership and compensa on arrangement prohibi ons (in-office
ancillary services); general excep ons related only to ownership or investment prohibi on for
ownership in publicly traded securi es and mutual funds (services furnished by a rural
provider); excep ons related to other compensa on arrangements (personal services
arrangements and rental of office space and equipment)
Office of the Inspector General (OIG)
, 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 Preven on (CDC), Na onal Ins tutes of Health (NIH), and the
Food and Drug Administra on (FDA)
OIG Work Plan
Published annually; lists the various projects that will be addressed during the fiscal year by the
Office of Audit Services, Office of Evalua on and Inspec ons, Office of Inves ga ons, and Office
of Counsel to the Inspector General; summarizes new and ongoing reviews and ac vi es 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?
It allows an auditor to inform providers and facili es 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 recommenda ons given to a prac ce
Corporate Integrity Agreements
Required by the OIG s a condi on of not seeking exclusion from par cipa on when an
individual or en ty seeks to seJle 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
en ty that are related to the conduct that led to the seJlement
Core requirements in CIAs
Hiring a compliance officer/appoin ng a compliance commiJee; developing wriJen standards
and policies; implemen ng a comprehensive employee training program; retaining an
independent review organiza on (IRO) to conduct annual reviews; establishing a confiden al
disclosure program; restric ng employment of ineligible persons; repor ng overpayments,
reportable events, and ongoing inves ga ons/legal proceedings; providing an implementa on
report and annual reports to the OIG on the status of the en ty's compliance ac vi es
Independent review organiza on (IRO)
Acts as a 3rd party medical review resource that provides objec ve, unbiased audits and reports
How many sampling units are selected for review in a Discovery Sample under a CIA?
50
Purpose of a Discovery Sample
A+ NEW EDITION
CMS Fraud Defini on
Making false statements or misrepresen ng facts to obtain an undeserved benefit or payment
from a federal healthcare program
CMS Abuse Defini on
An ac on that results in unnecessary costs to a federal healthcare program, either directly or
indirectly
CMS Examples of Fraud
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 pa ent above the
allowed amount for services, billing for services at a higher level than provided or necessary,
misrepresen ng the diagnosis to jus fy payment
CMS Examples of Abuse
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 prac ces, billing Medicare pa ents a higher fee schedule than non-Medicare
pa ents
False Claims Act
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 penal es
$5,500-$11,000 per claim
When does the False Claims Act allow for reduced penal es?
If the person commi0ng the viola on self-discloses and provides all known info within 30 days,
fully cooperates with the inves ga on, and there is no criminal prosecu on, civil ac on, or
administra ve ac on regarding the viola on
,Qui Tam or "Whistleblower" provision
If an individual (known as a "relator") knows of a viola on of the False Claims Act, he or she may
bring a civil ac on 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
Bans physicians from referring pa ents for certain services to en es in which the physician or
an immediate family member has a direct or indirect financial rela onship; bans the en ty from
billing Medicare or Medicaid for the services provided as a result of the self-referral
An -Kickback Law
Similar to the Stark Law but imposes more severe penal es; states that whoever knowingly or
willfully solicits or receives any remunera on 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 viola ng the An -Kickback Law
Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. An -Kickback Law
An -Kickback applies to anyone, not just physicians; the An -Kickback Law requires proof of
inten on and states that the person must "knowingly and willfully" violate the law.
Exclusion Statute
Under the Exclusion Statute, a physician who is convicted of a criminal offense—such as
Medicare fraud (both misdemeanor and felony convic ons), pa ent abuse and neglect, or illegal
distribu on of controlled substances—can be banned from par cipa ng 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 pa ents.
List of Excluded Individuals/En es (LEIE)
Produced and updated by the OIG; provides informa on regarding individuals and en es
currently excluded from par cipa on in Medicare, Medicaid, and all other federal healthcare
programs; sorts excluded individuals or en es by the legal basis for the exclusion, the types of
,individuals and en es that have been excluded, and the states where the excluded individual
resided at the me they were excluded or the state in which the en ty was doing business
Civil Monetary Penal es Law
The Social Security Act authorizes the HHS to seek civil monetary penal es and exclusion for
certain behaviors. These penal es are enforced by the OIG through the Civil Monetary Penal es
(CMP) Law. The severity of penal es 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:
Presen ng 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.Viola ng the An -Kickback Statute by knowingly and willfully (1) offering or paying
remunera on to induce the referral of federal healthcare program business, or (2) solici ng or
receiving remunera on in return for the referral of federal healthcare program business.
Knowingly presen ng or causing claims to be presented for a service for which payment may
not be made under the Stark law
Amount of civil monetary penal es
Range from $10,000-$50,000 per viola on and an assessment of up to 3 mes the amount of
the over-payments
Reverse False Claims sec on of the False Claims Act
Final sec on 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
Falsifying a medical chart nota on; submi0ng claims for services not performed, not requested,
or unnecessary; submi0ng claims for expired drugs; upcoding and/or unbundling services;
submi0ng claims for physician services performed by a non-physician provider without regard
to Incident-to guidelines
Excep ons to the Stark Law
General excep ons to both ownership and compensa on arrangement prohibi ons (in-office
ancillary services); general excep ons related only to ownership or investment prohibi on for
ownership in publicly traded securi es and mutual funds (services furnished by a rural
provider); excep ons related to other compensa on arrangements (personal services
arrangements and rental of office space and equipment)
Office of the Inspector General (OIG)
, 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 Preven on (CDC), Na onal Ins tutes of Health (NIH), and the
Food and Drug Administra on (FDA)
OIG Work Plan
Published annually; lists the various projects that will be addressed during the fiscal year by the
Office of Audit Services, Office of Evalua on and Inspec ons, Office of Inves ga ons, and Office
of Counsel to the Inspector General; summarizes new and ongoing reviews and ac vi es 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?
It allows an auditor to inform providers and facili es 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 recommenda ons given to a prac ce
Corporate Integrity Agreements
Required by the OIG s a condi on of not seeking exclusion from par cipa on when an
individual or en ty seeks to seJle 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
en ty that are related to the conduct that led to the seJlement
Core requirements in CIAs
Hiring a compliance officer/appoin ng a compliance commiJee; developing wriJen standards
and policies; implemen ng a comprehensive employee training program; retaining an
independent review organiza on (IRO) to conduct annual reviews; establishing a confiden al
disclosure program; restric ng employment of ineligible persons; repor ng overpayments,
reportable events, and ongoing inves ga ons/legal proceedings; providing an implementa on
report and annual reports to the OIG on the status of the en ty's compliance ac vi es
Independent review organiza on (IRO)
Acts as a 3rd party medical review resource that provides objec ve, unbiased audits and reports
How many sampling units are selected for review in a Discovery Sample under a CIA?
50
Purpose of a Discovery Sample
