CPCO Chapter 11 Review UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Can providers request an extension for providing records requested by an auditor if there is a
problem meeting the deadline? - CORRECT ANSWER - Yes, by calling the requestor and
explaining the reason for delay
Response Feedback:
Rationale: If there is a problem meeting the deadline, call the requestor to explain the reason for
the delay and ask for an extension.
What established the Medicaid Integrity Program? - CORRECT ANSWER - Section 1936 of
the Social Security Act
Response Feedback:
Section 1936 of the Social Security Act created the Medicaid Integrity Program (MIP) and
directed the CMS to enter into contracts to review Medicaid provider actions, audit claims,
identify overpayments, and educate providers and others on Medicaid program integrity issues.
The Compliance Officer asked the Billing Manager at Orange Hospital how many days they had
to send CERT contractor documentation. The Billing Manager said that documentation had to be
sent to the CERT contractor within: - CORRECT ANSWER - 75 days
Response Feedback:
75 days. The CERT documentation contractor may request medical records from the provider or
supplier who submitted the claim:
For some claim types (e.g., DMEPOS, clinical diagnostic laboratory services), additional
documentation requests are also made to the referring provider who ordered the item or service.
If no documentation is received within 75 days of the initial request, the claim is classified as a
"no documentation" claim and counted as an error.
, If documentation is received after 75 days of the initial request (late documentation), CERT will
still review the claim.
What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)? - CORRECT
ANSWER - Limited to investigating Medicaid provider fraud
Response Feedback:
Rationale: The jurisdiction of the Medicaid Fraud Control Units (MFCUs) is limited to
investigating and prosecuting Medicaid provider fraud. The MFCUs have prosecuted individual
providers such as physicians, dentists, and mental health professionals.
ZPICs target both the _______ of a claim and _____ errors - CORRECT ANSWER - medical
necessity, coding
Response Feedback:
ZPICs target both the medical necessity of a claim (e.g., whether it was covered according to
national or local coverage determinations and Medicare guidelines) and coding errors (e.g., DRG
and E/M services up-coding). ZPICs are responsible for ensuring the integrity of all Medicare-
related claims under Parts A and B (hospital, skilled nursing, home health, provider and DME
claims), Part C (Medicare Advantage health plans), Part D (prescription drug plans), and
coordination with the Medicare-Medicaid Data Match Program (Medi-Medi).
Which of the following is NOT TRUE regarding how improper payments are categorized? -
CORRECT ANSWER - Billed Based on Time
Response Feedback:
CMS and Contractors categorize improper payments as follows: No Documentation; Insufficient
Documentation; Medical Necessity; Incorrect Coding and Other.
What is NOT a typical way that providers try to defraud Medicaid? - CORRECT ANSWER -
Billing under several NPI's at a time
ACTUAL Exam Questions and CORRECT
Answers
Can providers request an extension for providing records requested by an auditor if there is a
problem meeting the deadline? - CORRECT ANSWER - Yes, by calling the requestor and
explaining the reason for delay
Response Feedback:
Rationale: If there is a problem meeting the deadline, call the requestor to explain the reason for
the delay and ask for an extension.
What established the Medicaid Integrity Program? - CORRECT ANSWER - Section 1936 of
the Social Security Act
Response Feedback:
Section 1936 of the Social Security Act created the Medicaid Integrity Program (MIP) and
directed the CMS to enter into contracts to review Medicaid provider actions, audit claims,
identify overpayments, and educate providers and others on Medicaid program integrity issues.
The Compliance Officer asked the Billing Manager at Orange Hospital how many days they had
to send CERT contractor documentation. The Billing Manager said that documentation had to be
sent to the CERT contractor within: - CORRECT ANSWER - 75 days
Response Feedback:
75 days. The CERT documentation contractor may request medical records from the provider or
supplier who submitted the claim:
For some claim types (e.g., DMEPOS, clinical diagnostic laboratory services), additional
documentation requests are also made to the referring provider who ordered the item or service.
If no documentation is received within 75 days of the initial request, the claim is classified as a
"no documentation" claim and counted as an error.
, If documentation is received after 75 days of the initial request (late documentation), CERT will
still review the claim.
What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)? - CORRECT
ANSWER - Limited to investigating Medicaid provider fraud
Response Feedback:
Rationale: The jurisdiction of the Medicaid Fraud Control Units (MFCUs) is limited to
investigating and prosecuting Medicaid provider fraud. The MFCUs have prosecuted individual
providers such as physicians, dentists, and mental health professionals.
ZPICs target both the _______ of a claim and _____ errors - CORRECT ANSWER - medical
necessity, coding
Response Feedback:
ZPICs target both the medical necessity of a claim (e.g., whether it was covered according to
national or local coverage determinations and Medicare guidelines) and coding errors (e.g., DRG
and E/M services up-coding). ZPICs are responsible for ensuring the integrity of all Medicare-
related claims under Parts A and B (hospital, skilled nursing, home health, provider and DME
claims), Part C (Medicare Advantage health plans), Part D (prescription drug plans), and
coordination with the Medicare-Medicaid Data Match Program (Medi-Medi).
Which of the following is NOT TRUE regarding how improper payments are categorized? -
CORRECT ANSWER - Billed Based on Time
Response Feedback:
CMS and Contractors categorize improper payments as follows: No Documentation; Insufficient
Documentation; Medical Necessity; Incorrect Coding and Other.
What is NOT a typical way that providers try to defraud Medicaid? - CORRECT ANSWER -
Billing under several NPI's at a time
