CPPM STUDY QUESTIONS FOR EXAM_UPDATE AND CORRECTLY ANSWERED 2024 A+ GRADED 100%

CPPM STUDY QUESTIONS FOR EXAM_UPDATE AND CORRECTLY ANSWERED 2024 A+ GRADED 100% Carve Out Policy - CORRECT ANSWER-A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment. Which isn't 1 of the 7 core elements of a compliance plan? a. Adequate compliance standards and procedures. b. Monitoring, auditing, and hot lines. c. Third-party audit by certified coders. d. Enforcement of violations. - CORRECT ANSWER-c. Third-party audit by certified coders. A rebate or "referral fee" paid to a Primary Care Provider for referrals to a cardiologist is known as a: - CORRECT ANSWER-It's a kickback and illegal under Stark Laws. What is the significance of CLIA? - CORRECT ANSWER-Clinical Laboratory Improvement Amendments (CLIA) of 1988 are U.S. federal regulatory standards that apply to all clinical laboratories. Which is an example of provider fraud? a. Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary. b. Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery. c. Upcoding, billing, for a service that is more costly than the one actually performed. d. All of the answers are correct. - CORRECT ANSWER-d. All of the answers are correct. The False Claims statute: - CORRECT ANSWER-makes it illegal for any health care provider to submit to Medicare or Medicaid bills that contain charges for items or services furnished substantially in excess of its " usual charges." What is the Medicare "Whistleblower" program? - CORRECT ANSWER-it is an official program for turning in fraudulent Medicare Providers DME is durable medical equipment. It would apply to any instance of fraud. Which is not 1 of 7 components recommended by the OIG? - CORRECT ANSWER-a. Effective Lines of Communication b. Enforcing Standards through Well- Published Disciplinary Guidelines c. Auditing and Monitoring d. Credentialing What regulations must an in-house laboratory adhere to? - CORRECT ANSWER-Clinical Laboratory Improvement Amendment (CLIA) regulations. Intentional deception or misrepresentation intended to result in an unauthorized benefit is known as: - CORRECT ANSWER-Fraud What is true about the False Claims Act (FCA)? - CORRECT ANSWER-The FCA permits a person with knowledge of fraud against the U.S. Government, to file a lawsuit on behalf of the government against the person or business that committed the fraud. Ther have been several large claims submitted. A kickback is: - CORRECT ANSWER-an offer to pay, solicit, or receive any compensation in any form, either directly or indirectly, in return for referring or generating services or other business for which payment may be made under Medicare or other Federal Health Care Programs. This rule only applies to federal or state programs including Medicare or Medicaid. The False Claims Act (FCA): - CORRECT ANSWER-is a federal statute that covers fraud involving any federally funded contract or program, including Medicare and Medicaid. -establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the government for payment. -does not require proof of a specific intent to defraud the government. Charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced is known as: - CORRECT ANSWER-abuse Emergency services should be provided in accordance with: - CORRECT ANSWER-Emergency Medical Treatment and Active Labor Act (EMTALA) It is permissible to waive patient co-payments or deductibles: - CORRECT ANSWER-never Which is a task that the OIG does not conduct? a. audits, evaluations, and investigations b. providing guidance to industry. c. imposing civil monetary penalties (CMP) d. all of the answers are correct. - CORRECT ANSWER-d. all of the answers are correct. What is the role of JCAHO? - CORRECT ANSWER-operates fee-based, accreditation programs to subscriber hospitals and other healthcare organizations. Which is not a focus of the OIG Work Plan? - CORRECT ANSWER-Training What is the significance of the Stark Laws? - CORRECT ANSWER-These laws prohibit a physician from referring a Medicare patient to an entity for certain designated health services if the physician has a financial relationship with the entity that bills Medicare. A hospital Emergency Department (ED) must be: - CORRECT ANSWER-Accessible 24 hours a day, every day A Medicare Participating Provider is: a. a provider who accepts assignments for Medicare Claims b. a provider who only charges the patient according to the Medicare Fee Schedule. c. who participates in the Medicare Plus Choices Program. d. all of the above - CORRECT ANSWER-d. all of the above What is the definition of a composite APC? - CORRECT ANSWER-Medicare pays a single rate for a service that is reported with a combination of HCPCS comments on the same date or different date of service rather than paying for each procedure or service under a specific APC. CMS has delineated three mechanisms for payment of medical and surgical procedures (inpatient vs outpatient): - CORRECT ANSWER-Outpatient Surgical Services (APC reimbursed procedures not on the "inpatient only" list); Inpatient Surgical Services (DRG reimbursed) Freestanding ASC (Fee-based) Where would one find "timely filing" information for an Insurance Carrier? a. all carriers follow the PFRSRVU Medicare database TFI guidelines b. CPT Manual c. AHA Coding Clinic d. Each carrier publishes their own Timely Filing Period - CORRECT ANSWER-d. Each carrier publishes their own Timely Filing Period Which of the following would be MOST correct concerning ABN's (Advanced Beneficiary Notice? a. ABN's were introduced in 2015 b. ABN's were replaced with the advent of HIPAA c. ABN's would rarely be used in a pediatric facility d. None of the answers are correct. - CORRECT ANSWER-c. ABN's would rarely be used in a pediatric facility. HR - CORRECT ANSWER-Human resources. Department responsible for recruitment and retention of employees while maintaining compliance with applicable employment laws. Open ended questions - CORRECT ANSWER-questions that allow respondents to answer however they want Case based questions or tests - CORRECT ANSWER-Time keyboarding, evaluating and rewriting a contract, calculating an accounting based problem. Behavioral questions - CORRECT ANSWER-Questions that ask the candidate to explain how they responded to a situation in the past, or how they would respond to a hypothetical situation. Aptitude or general intelligence test - CORRECT ANSWER-Designed to predict job performance and measure and applicant's overall intelligence and ability to learn.