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CPCO Chapter 11 Review Questions and Verified
Answers
Can providers request an extension for providing records requested by an
auditor if there is a problem meeting the deadline?
Ans: 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?
Ans: 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:
Ans: 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.
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What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)?
Ans: 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
Ans: 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?
Ans: 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?
CPCO Chapter 11 Review Questions and Verified
Answers
Can providers request an extension for providing records requested by an
auditor if there is a problem meeting the deadline?
Ans: 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?
Ans: 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:
Ans: 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.
, Page | 2
What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)?
Ans: 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
Ans: 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?
Ans: 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?
