CPMA Certification Study Guide 2018
Chapter 1, Questions and answers,
100% Accurate, Verified.
How does CMS define fraud? - ✔✔-Making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from a federal healthcare program.
How does CMS define abuse? - ✔✔-An action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
CMS Example 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 for services at a higher level than provided or necessary
Misrepresenting the diagnosis to justify 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 practices
Billing Medicare patients a higher fee schedule than non-Medicare patients
Federal False Claims Act - ✔✔-A law that allows for individuals to bring civil actions on behalf of the U.S.
government for false claims made to the federal government, under a provision of the law called qui
tam (from Latin meaning "to bring an action for the king and for oneself").
Examples of fraud or misconduct subject to the False Claims Act include: - ✔✔-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
The FCA allows for reduced penalties (mitigation) if the person committing the violation self-discloses,
and if: - ✔✔-* the person responsible furnishes officials of the U.S. responsible for investigating false
claims violations with all information known to such person about the violation within 30 days after the
date on which the defendant first obtained the information
* such person fully cooperates with the investigation of such violation
* at the time such person furnishes the information about the violation, no criminal prosecution, civil
action, or administrative action has commenced under this title with respect to such violation, and the
person did not have actual knowledge of the existence of an investigation into such violation
Qui Tam Action - ✔✔-An action to recover a penalty brought on by an informer in a situation in which
one portion of the recovery goes to the informer and the other portion to the state or government.
What defines a financial relationship among entities? - ✔✔-a direct or indirect ownership interest,
investment interest, or compensation arrangement with any entity that furnishes a DHS
What is the Stark Law? - ✔✔-prohibits a physician from referring patients for certain designated health
services (Medicare & Medicaid) to entities with whom the physician has a financial relationship
What is the Anti-Kickback law? - ✔✔-Similar to Stark Law but imposes more severe penalties. States that
whoever knowingly and willfully solicits or receives any remuneration:
a) In return for referring an individual to a person for the furnishing or arranging for the furnishing of
any item or service for which payment may be made in whole or in part under a federal healthcare
program, or...
b) 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...
Chapter 1, Questions and answers,
100% Accurate, Verified.
How does CMS define fraud? - ✔✔-Making false statements or misrepresenting facts to obtain an
undeserved benefit or payment from a federal healthcare program.
How does CMS define abuse? - ✔✔-An action that results in unnecessary costs to a federal healthcare
program, either directly or indirectly
CMS Example 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 for services at a higher level than provided or necessary
Misrepresenting the diagnosis to justify 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 practices
Billing Medicare patients a higher fee schedule than non-Medicare patients
Federal False Claims Act - ✔✔-A law that allows for individuals to bring civil actions on behalf of the U.S.
government for false claims made to the federal government, under a provision of the law called qui
tam (from Latin meaning "to bring an action for the king and for oneself").
Examples of fraud or misconduct subject to the False Claims Act include: - ✔✔-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
The FCA allows for reduced penalties (mitigation) if the person committing the violation self-discloses,
and if: - ✔✔-* the person responsible furnishes officials of the U.S. responsible for investigating false
claims violations with all information known to such person about the violation within 30 days after the
date on which the defendant first obtained the information
* such person fully cooperates with the investigation of such violation
* at the time such person furnishes the information about the violation, no criminal prosecution, civil
action, or administrative action has commenced under this title with respect to such violation, and the
person did not have actual knowledge of the existence of an investigation into such violation
Qui Tam Action - ✔✔-An action to recover a penalty brought on by an informer in a situation in which
one portion of the recovery goes to the informer and the other portion to the state or government.
What defines a financial relationship among entities? - ✔✔-a direct or indirect ownership interest,
investment interest, or compensation arrangement with any entity that furnishes a DHS
What is the Stark Law? - ✔✔-prohibits a physician from referring patients for certain designated health
services (Medicare & Medicaid) to entities with whom the physician has a financial relationship
What is the Anti-Kickback law? - ✔✔-Similar to Stark Law but imposes more severe penalties. States that
whoever knowingly and willfully solicits or receives any remuneration:
a) In return for referring an individual to a person for the furnishing or arranging for the furnishing of
any item or service for which payment may be made in whole or in part under a federal healthcare
program, or...
b) 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...
