CMS Medicare & Medicaid Compliance Exam Prep |
Comprehensive QUESTION Bank & Detailed Explanations
Verified Answers & Detailed Rationales (2026/2027)
QUESTION 1
Which of the following best defines "Fraud" in the context of CMS
compliance?
• A. Mistakes made during the medical billing process due to lack of
training.
• B. An intentional deception or misrepresentation made by a
person with the knowledge that the deception could result in
some unauthorized benefit.
• C. Unnecessary costs that occur due to inefficient business
practices.
• D. Providing services that are not medically necessary, but billing
them as necessary.
Correct Answer: B. An intentional deception or misrepresentation made
by a person with the knowledge that the deception could result in some
unauthorized benefit.
Detailed Rationale: Fraud is specifically defined by the intent to
deceive. Waste and abuse often involve mistakes or inefficiency, but
fraud requires "knowing and willful" deception to receive payment.
QUESTION 2
,Which federal law prohibits offering, paying, soliciting, or receiving
anything of value to induce or reward referrals for items or services
reimbursed by federal health care programs?
• A. The False Claims Act
• B. The Anti-Kickback Statute (AKS)
• C. The Stark Law
• D. The Emergency Medical Treatment and Labor Act (EMTALA)
Correct Answer: B. The Anti-Kickback Statute (AKS)
Detailed Rationale: The Anti-Kickback Statute is a criminal statute that
prohibits the exchange of anything of value (remuneration) in return for
referrals of federal health care program business.
QUESTION 3
The Stark Law (Physician Self-Referral Law) specifically prohibits a
physician from making referrals for certain designated health services to
an entity if:
• A. The physician has a financial relationship with that entity.
• B. The entity is located in a different state.
• C. The patient has private insurance rather than Medicare.
• D. The physician has never met the patient before.
Correct Answer: A. The physician has a financial relationship with that
entity.
Detailed Rationale: The Stark Law prohibits physicians from referring
Medicare patients for designated health services (DHS) to an entity with
,which they (or an immediate family member) have a financial
relationship, unless an exception applies.
QUESTION 4
What is the primary purpose of the False Claims Act (FCA)?
• A. To mandate the use of electronic health records.
• B. To protect the government from being overcharged or sold
substandard goods or services.
• C. To regulate the quality of care in nursing homes.
• D. To provide privacy protections for patient data.
Correct Answer: B. To protect the government from being overcharged
or sold substandard goods or services.
Detailed Rationale: The FCA imposes liability on persons and
companies that defraud governmental programs. It prohibits the
submission of "false" or "fraudulent" claims for payment to the
government.
QUESTION 5
Which of the following is NOT one of the seven elements of an effective
compliance program required by the OIG?
• A. Implementing written policies, procedures, and standards of
conduct.
• B. Designating a Compliance Officer and Compliance Committee.
• C. Limiting access to patient records to prevent audits.
• D. Conducting effective training and education.
, Correct Answer: C. Limiting access to patient records to prevent audits.
Detailed Rationale: The OIG (Office of Inspector General) lists internal
monitoring and auditing as a core element, not limiting access to avoid
audits. Transparency and auditing are essential for compliance.
QUESTION 6
Under EMTALA, a hospital with a dedicated emergency department
must provide which of the following to any individual who comes to the
department with an emergency medical condition?
• A. Only those services covered by the patient's insurance.
• B. A Medical Screening Examination (MSE) to determine if an
emergency medical condition exists.
• C. A full course of treatment, regardless of the patient's ability to
pay.
• D. Immediate transfer to a specialist facility.
Correct Answer: B. A Medical Screening Examination (MSE) to
determine if an emergency medical condition exists.
Detailed Rationale: EMTALA requires hospitals to provide an
appropriate medical screening examination to any individual who
comes to the emergency department, regardless of their ability to pay,
to determine if an emergency condition exists.
QUESTION 7
What is the "Minimum Necessary" rule under HIPAA?
• A. Providers should only use the minimum amount of PHI
necessary to accomplish the intended purpose.
Comprehensive QUESTION Bank & Detailed Explanations
Verified Answers & Detailed Rationales (2026/2027)
QUESTION 1
Which of the following best defines "Fraud" in the context of CMS
compliance?
• A. Mistakes made during the medical billing process due to lack of
training.
• B. An intentional deception or misrepresentation made by a
person with the knowledge that the deception could result in
some unauthorized benefit.
• C. Unnecessary costs that occur due to inefficient business
practices.
• D. Providing services that are not medically necessary, but billing
them as necessary.
Correct Answer: B. An intentional deception or misrepresentation made
by a person with the knowledge that the deception could result in some
unauthorized benefit.
Detailed Rationale: Fraud is specifically defined by the intent to
deceive. Waste and abuse often involve mistakes or inefficiency, but
fraud requires "knowing and willful" deception to receive payment.
QUESTION 2
,Which federal law prohibits offering, paying, soliciting, or receiving
anything of value to induce or reward referrals for items or services
reimbursed by federal health care programs?
• A. The False Claims Act
• B. The Anti-Kickback Statute (AKS)
• C. The Stark Law
• D. The Emergency Medical Treatment and Labor Act (EMTALA)
Correct Answer: B. The Anti-Kickback Statute (AKS)
Detailed Rationale: The Anti-Kickback Statute is a criminal statute that
prohibits the exchange of anything of value (remuneration) in return for
referrals of federal health care program business.
QUESTION 3
The Stark Law (Physician Self-Referral Law) specifically prohibits a
physician from making referrals for certain designated health services to
an entity if:
• A. The physician has a financial relationship with that entity.
• B. The entity is located in a different state.
• C. The patient has private insurance rather than Medicare.
• D. The physician has never met the patient before.
Correct Answer: A. The physician has a financial relationship with that
entity.
Detailed Rationale: The Stark Law prohibits physicians from referring
Medicare patients for designated health services (DHS) to an entity with
,which they (or an immediate family member) have a financial
relationship, unless an exception applies.
QUESTION 4
What is the primary purpose of the False Claims Act (FCA)?
• A. To mandate the use of electronic health records.
• B. To protect the government from being overcharged or sold
substandard goods or services.
• C. To regulate the quality of care in nursing homes.
• D. To provide privacy protections for patient data.
Correct Answer: B. To protect the government from being overcharged
or sold substandard goods or services.
Detailed Rationale: The FCA imposes liability on persons and
companies that defraud governmental programs. It prohibits the
submission of "false" or "fraudulent" claims for payment to the
government.
QUESTION 5
Which of the following is NOT one of the seven elements of an effective
compliance program required by the OIG?
• A. Implementing written policies, procedures, and standards of
conduct.
• B. Designating a Compliance Officer and Compliance Committee.
• C. Limiting access to patient records to prevent audits.
• D. Conducting effective training and education.
, Correct Answer: C. Limiting access to patient records to prevent audits.
Detailed Rationale: The OIG (Office of Inspector General) lists internal
monitoring and auditing as a core element, not limiting access to avoid
audits. Transparency and auditing are essential for compliance.
QUESTION 6
Under EMTALA, a hospital with a dedicated emergency department
must provide which of the following to any individual who comes to the
department with an emergency medical condition?
• A. Only those services covered by the patient's insurance.
• B. A Medical Screening Examination (MSE) to determine if an
emergency medical condition exists.
• C. A full course of treatment, regardless of the patient's ability to
pay.
• D. Immediate transfer to a specialist facility.
Correct Answer: B. A Medical Screening Examination (MSE) to
determine if an emergency medical condition exists.
Detailed Rationale: EMTALA requires hospitals to provide an
appropriate medical screening examination to any individual who
comes to the emergency department, regardless of their ability to pay,
to determine if an emergency condition exists.
QUESTION 7
What is the "Minimum Necessary" rule under HIPAA?
• A. Providers should only use the minimum amount of PHI
necessary to accomplish the intended purpose.
