CPMA Exam With complete solutions
2024/2025
CMS Fraud Definition - ANSWER-Making false statements or misrepresenting
facts to obtain an undeserved benefit or payment from a federal healthcare
program
CMS Abuse Definition - ANSWER-An action that results in unnecessary costs to a
federal healthcare program, either directly or indirectly
CMS Examples of Fraud - ANSWER-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 patient above the allowed
amount for services, billing for services at a higher level than provided or
necessary, misrepresenting the diagnosis to justify payment
CMS Examples of Abuse - ANSWER-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
False Claims Act - ANSWER-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 penalties - ANSWER-$5,500-$11,000 per claim
,When does the False Claims Act allow for reduced penalties? - ANSWER-If the
person committing the violation self-discloses and provides all known info within
30 days, fully cooperates with the investigation, and there is no criminal
prosecution, civil action, or administrative action regarding the violation
Qui Tam or "Whistleblower" provision - ANSWER-If an individual (known as a
"relator") knows of a violation of the False Claims Act, he or she may bring a civil
action 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 - ANSWER-Bans physicians from referring
patients for certain services to entities in which the physician or an immediate
family member has a direct or indirect financial relationship; bans the entity from
billing Medicare or Medicaid for the services provided as a result of the self-
referral
Anti-Kickback Law - ANSWER-Similar to the Stark Law but imposes more severe
penalties; states that whoever knowingly or willfully solicits or receives any
remuneration 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 violating the Anti-Kickback Law - ANSWER-Up to $25,000 fine and/or
imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - ANSWER-Anti-Kickback applies to anyone, not
just physicians; the Anti-Kickback Law requires proof of intention and states that
the person must "knowingly and willfully" violate the law.
Exclusion Statute - ANSWER-Under the Exclusion Statute, a physician who is
convicted of a criminal offense—such as Medicare fraud (both misdemeanor and
felony convictions), patient abuse and neglect, or illegal distribution of controlled
substances—can be banned from participating 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 patients.
List of Excluded Individuals/Entities (LEIE) - ANSWER-Produced and updated by
the OIG; provides information regarding individuals and entities currently
,excluded from participation in Medicare, Medicaid, and all other federal
healthcare programs; sorts excluded individuals or entities by the legal basis for
the exclusion, the types of individuals and entities that have been excluded, and
the states where the excluded individual resided at the time they were excluded
or the state in which the entity was doing business
Civil Monetary Penalties Law - ANSWER-The Social Security Act authorizes the
HHS to seek civil monetary penalties and exclusion for certain behaviors. These
penalties are enforced by the OIG through the Civil Monetary Penalties (CMP)
Law. The severity of penalties 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: Presenting 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.Violating the
Anti-Kickback Statute by knowingly and willfully (1) offering or paying
remuneration to induce the referral of federal healthcare program business, or (2)
soliciting or receiving remuneration in return for the referral of federal healthcare
program business. Knowingly presenting or causing claims to be presented for a
service for which payment may not be made under the Stark law
Amount of civil monetary penalties - ANSWER-Range from $10,000-$50,000 per
violation and an assessment of up to 3 times the amount of the over-payments
Reverse False Claims section of the False Claims Act - ANSWER-Final section
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 - ANSWER-
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
Exceptions to the Stark Law - ANSWER-General exceptions to both ownership
and compensation arrangement prohibitions (in-office ancillary services); general
exceptions related only to ownership or investment prohibition for ownership in
publicly traded securities and mutual funds (services furnished by a rural
provider); exceptions related to other compensation arrangements (personal
services arrangements and rental of office space and equipment)
, Office of the Inspector General (OIG) - ANSWER-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 Prevention (CDC), National Institutes of Health
(NIH), and the Food and Drug Administration (FDA)
OIG Work Plan - ANSWER-Published annually; lists the various projects that will
be addressed during the fiscal year by the Office of Audit Services, Office of
Evaluation and Inspections, Office of Investigations, and Office of Counsel to the
Inspector General; summarizes new and ongoing reviews and activities 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? -
ANSWER-It allows an auditor to inform providers and facilities 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
recommendations given to a practice
Corporate Integrity Agreements - ANSWER-Required by the OIG s a condition of
not seeking exclusion from participation when an individual or entity seeks to
settle 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
entity that are related to the conduct that led to the settlement
Core requirements in CIAs - ANSWER-Hiring a compliance officer/appointing a
compliance committee; developing written standards and policies; implementing
a comprehensive employee training program; retaining an independent review
organization (IRO) to conduct annual reviews; establishing a confidential
disclosure program; restricting employment of ineligible persons; reporting
overpayments, reportable events, and ongoing investigations/legal proceedings;
providing an implementation report and annual reports to the OIG on the status of
the entity's compliance activities
Independent review organization (IRO) - ANSWER-Acts as a 3rd party medical
review resource that provides objective, unbiased audits and reports
How many sampling units are selected for review in a Discovery Sample under a
CIA? - ANSWER-50
2024/2025
CMS Fraud Definition - ANSWER-Making false statements or misrepresenting
facts to obtain an undeserved benefit or payment from a federal healthcare
program
CMS Abuse Definition - ANSWER-An action that results in unnecessary costs to a
federal healthcare program, either directly or indirectly
CMS Examples of Fraud - ANSWER-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 patient above the allowed
amount for services, billing for services at a higher level than provided or
necessary, misrepresenting the diagnosis to justify payment
CMS Examples of Abuse - ANSWER-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
False Claims Act - ANSWER-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 penalties - ANSWER-$5,500-$11,000 per claim
,When does the False Claims Act allow for reduced penalties? - ANSWER-If the
person committing the violation self-discloses and provides all known info within
30 days, fully cooperates with the investigation, and there is no criminal
prosecution, civil action, or administrative action regarding the violation
Qui Tam or "Whistleblower" provision - ANSWER-If an individual (known as a
"relator") knows of a violation of the False Claims Act, he or she may bring a civil
action 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 - ANSWER-Bans physicians from referring
patients for certain services to entities in which the physician or an immediate
family member has a direct or indirect financial relationship; bans the entity from
billing Medicare or Medicaid for the services provided as a result of the self-
referral
Anti-Kickback Law - ANSWER-Similar to the Stark Law but imposes more severe
penalties; states that whoever knowingly or willfully solicits or receives any
remuneration 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 violating the Anti-Kickback Law - ANSWER-Up to $25,000 fine and/or
imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - ANSWER-Anti-Kickback applies to anyone, not
just physicians; the Anti-Kickback Law requires proof of intention and states that
the person must "knowingly and willfully" violate the law.
Exclusion Statute - ANSWER-Under the Exclusion Statute, a physician who is
convicted of a criminal offense—such as Medicare fraud (both misdemeanor and
felony convictions), patient abuse and neglect, or illegal distribution of controlled
substances—can be banned from participating 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 patients.
List of Excluded Individuals/Entities (LEIE) - ANSWER-Produced and updated by
the OIG; provides information regarding individuals and entities currently
,excluded from participation in Medicare, Medicaid, and all other federal
healthcare programs; sorts excluded individuals or entities by the legal basis for
the exclusion, the types of individuals and entities that have been excluded, and
the states where the excluded individual resided at the time they were excluded
or the state in which the entity was doing business
Civil Monetary Penalties Law - ANSWER-The Social Security Act authorizes the
HHS to seek civil monetary penalties and exclusion for certain behaviors. These
penalties are enforced by the OIG through the Civil Monetary Penalties (CMP)
Law. The severity of penalties 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: Presenting 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.Violating the
Anti-Kickback Statute by knowingly and willfully (1) offering or paying
remuneration to induce the referral of federal healthcare program business, or (2)
soliciting or receiving remuneration in return for the referral of federal healthcare
program business. Knowingly presenting or causing claims to be presented for a
service for which payment may not be made under the Stark law
Amount of civil monetary penalties - ANSWER-Range from $10,000-$50,000 per
violation and an assessment of up to 3 times the amount of the over-payments
Reverse False Claims section of the False Claims Act - ANSWER-Final section
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 - ANSWER-
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
Exceptions to the Stark Law - ANSWER-General exceptions to both ownership
and compensation arrangement prohibitions (in-office ancillary services); general
exceptions related only to ownership or investment prohibition for ownership in
publicly traded securities and mutual funds (services furnished by a rural
provider); exceptions related to other compensation arrangements (personal
services arrangements and rental of office space and equipment)
, Office of the Inspector General (OIG) - ANSWER-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 Prevention (CDC), National Institutes of Health
(NIH), and the Food and Drug Administration (FDA)
OIG Work Plan - ANSWER-Published annually; lists the various projects that will
be addressed during the fiscal year by the Office of Audit Services, Office of
Evaluation and Inspections, Office of Investigations, and Office of Counsel to the
Inspector General; summarizes new and ongoing reviews and activities 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? -
ANSWER-It allows an auditor to inform providers and facilities 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
recommendations given to a practice
Corporate Integrity Agreements - ANSWER-Required by the OIG s a condition of
not seeking exclusion from participation when an individual or entity seeks to
settle 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
entity that are related to the conduct that led to the settlement
Core requirements in CIAs - ANSWER-Hiring a compliance officer/appointing a
compliance committee; developing written standards and policies; implementing
a comprehensive employee training program; retaining an independent review
organization (IRO) to conduct annual reviews; establishing a confidential
disclosure program; restricting employment of ineligible persons; reporting
overpayments, reportable events, and ongoing investigations/legal proceedings;
providing an implementation report and annual reports to the OIG on the status of
the entity's compliance activities
Independent review organization (IRO) - ANSWER-Acts as a 3rd party medical
review resource that provides objective, unbiased audits and reports
How many sampling units are selected for review in a Discovery Sample under a
CIA? - ANSWER-50
