ABQAURP COMPREHENSIVE QUESTIONS AND
ANSWERS SURE A+
✔✔What two systems did CMS implement in 2006 to integrate claims information and
improve its ability to detect fraud, waste, and abuse? - ✔✔Integrated Data Repository
(IDR) and One Program Integrity (One PI)
✔✔What are the six areas of program integrity activity monitoring CMS contracts private
entities to monitor? - ✔✔-Provider Audits
-Reviewing claims for medical necessity
-Identifying and investigating fraud
-Ensuring that Medicare pays only for services for which it has primary responsibility
-Educating providers on Medicare billing procedures
-Identifying improper billing practices that affect both Medicare and Medicaid
✔✔What entity did CMS create in 2010 to consolidate responsibility for administering
and monitoring program integrity activities? - ✔✔Center for Program Integrity (CPI)
✔✔What are CPI's 4 areas? - ✔✔-Prevention
-Detection
-Recovery
-Transparency
✔✔What is the CNC? - ✔✔Compromised Number Checklist: a database of Medicare
beneficiary HICNs (Healthcare Insurance Claim Number) and provider ID numbers felt
to be compromise
✔✔What is the CTI "Four Pillar" approach? - ✔✔1. Assistance with medication self-
management.
2. Keeping an updated patient-centered record to facilitate information transfer between
care
providers.Scheduling timely follow-up appointments with primary or specialty care.
, 3. Understanding "red flag" events and what to do in response should one occur
✔✔Medicare Part A? - ✔✔Pays for inpatient hospital, SNF, home health (related to a
hospital stay), and hospice care - Financed by a 2.9% payroll tax split between
employees and employers
✔✔Medicare Part B? - ✔✔Pays for physician, outpatient hospital, ESRD, laboratory,
DME, certain home health, and other medical services. Part B coverage is voluntary
and funded 25% by premiums and 75% by general government revenues
✔✔Medicare part C? - ✔✔Medicare advantage program. The MA plans are are
generally private managed care companies that are paid by the government a capitated,
monthly payment to provide all Part A and B services, and also Part D services if
offered by the plan
✔✔Medicare Part D? - ✔✔Standard prescription drug benefit. Optional, beneficiaries
who choose to participate are responsible for covering a portion of the cost of their
prescription drugs
✔✔Medicaid? - ✔✔Cooperative federal-state program that provides medical care to
needy individuals. To qualify for federal funds states must submit their Medicaid plan to
CMS. CMS reviews to determine if plan complied with federal regulation that "assure
that payments are consistent with efficiency, economy, and quality of care and are
sufficient to enlist enough providers [to make Medicaid] care and services . . . available"
✔✔23 hour obs - ✔✔2 midnight rule, the laws applications,
✔✔ Who initially decided quality should be measured - ✔✔Abraham Flexner
✔✔Lead the founding of the Joint Commission - ✔✔E.A. Codman
✔✔Brought modern quality assurance techniques to moder medicine - ✔✔Avedis
Donabedian
✔✔Named the PDCA cycle - ✔✔W. Edwards Deming
✔✔Developed the PDCA cycle - ✔✔Walter Shewhart
✔✔Deming's seven diseases - ✔✔1.) Lack of consistency of purpose
2.) Emphasis on short-term profits
3.) Evaluation of performance, merit rating or annual review
4.) Mobility of management (job hopping)
5.) management by use of "visible figures", with no consideration of unknowns or
unknowables
6.) Excessive medical costs
ANSWERS SURE A+
✔✔What two systems did CMS implement in 2006 to integrate claims information and
improve its ability to detect fraud, waste, and abuse? - ✔✔Integrated Data Repository
(IDR) and One Program Integrity (One PI)
✔✔What are the six areas of program integrity activity monitoring CMS contracts private
entities to monitor? - ✔✔-Provider Audits
-Reviewing claims for medical necessity
-Identifying and investigating fraud
-Ensuring that Medicare pays only for services for which it has primary responsibility
-Educating providers on Medicare billing procedures
-Identifying improper billing practices that affect both Medicare and Medicaid
✔✔What entity did CMS create in 2010 to consolidate responsibility for administering
and monitoring program integrity activities? - ✔✔Center for Program Integrity (CPI)
✔✔What are CPI's 4 areas? - ✔✔-Prevention
-Detection
-Recovery
-Transparency
✔✔What is the CNC? - ✔✔Compromised Number Checklist: a database of Medicare
beneficiary HICNs (Healthcare Insurance Claim Number) and provider ID numbers felt
to be compromise
✔✔What is the CTI "Four Pillar" approach? - ✔✔1. Assistance with medication self-
management.
2. Keeping an updated patient-centered record to facilitate information transfer between
care
providers.Scheduling timely follow-up appointments with primary or specialty care.
, 3. Understanding "red flag" events and what to do in response should one occur
✔✔Medicare Part A? - ✔✔Pays for inpatient hospital, SNF, home health (related to a
hospital stay), and hospice care - Financed by a 2.9% payroll tax split between
employees and employers
✔✔Medicare Part B? - ✔✔Pays for physician, outpatient hospital, ESRD, laboratory,
DME, certain home health, and other medical services. Part B coverage is voluntary
and funded 25% by premiums and 75% by general government revenues
✔✔Medicare part C? - ✔✔Medicare advantage program. The MA plans are are
generally private managed care companies that are paid by the government a capitated,
monthly payment to provide all Part A and B services, and also Part D services if
offered by the plan
✔✔Medicare Part D? - ✔✔Standard prescription drug benefit. Optional, beneficiaries
who choose to participate are responsible for covering a portion of the cost of their
prescription drugs
✔✔Medicaid? - ✔✔Cooperative federal-state program that provides medical care to
needy individuals. To qualify for federal funds states must submit their Medicaid plan to
CMS. CMS reviews to determine if plan complied with federal regulation that "assure
that payments are consistent with efficiency, economy, and quality of care and are
sufficient to enlist enough providers [to make Medicaid] care and services . . . available"
✔✔23 hour obs - ✔✔2 midnight rule, the laws applications,
✔✔ Who initially decided quality should be measured - ✔✔Abraham Flexner
✔✔Lead the founding of the Joint Commission - ✔✔E.A. Codman
✔✔Brought modern quality assurance techniques to moder medicine - ✔✔Avedis
Donabedian
✔✔Named the PDCA cycle - ✔✔W. Edwards Deming
✔✔Developed the PDCA cycle - ✔✔Walter Shewhart
✔✔Deming's seven diseases - ✔✔1.) Lack of consistency of purpose
2.) Emphasis on short-term profits
3.) Evaluation of performance, merit rating or annual review
4.) Mobility of management (job hopping)
5.) management by use of "visible figures", with no consideration of unknowns or
unknowables
6.) Excessive medical costs
