CDEO CHAPTER 3 EXAM QUESTIONS
AND ANSWERS
Documentation states that the patient had a "Status post hysterectomy. The patient
presents with a fever." Which of the following would be a compliant question to query? -
Correct Answers -Do you know the cause of the fever?
Fraud - Correct Answers -Fraud is an intentional deception or misrepresentation of the
fact that can result in unauthorized benefits or payment. In this case, billing for services
at a higher level than provided would be considered intentional, and therefore
fraudulent.
When a provider is excluded under the Exclusions Statute, what must he or she do at
the end of the exclusionary period? - Correct Answers -The provider must apply for
reinstatement.
OIG has identified seven elements - Correct Answers -1-Implementing written policies,
procedures and standards of conduct;
2-Designating a compliance officer and/or compliance committee;
3-Conducting effective training and education;
4-Developing effective lines of communication;
5-Enforcing standards through well-publicized disciplinary guidelines;
6-Conducting internal monitoring and auditing; and
7-Responding promptly to detected offenses and developing corrective action
Operation Restore Trust - Correct Answers -3 offices were involved: OIG, Healthcare
Financing Administration, AoA
May 1995 Bill Clinton: 2 yr partnership of federal and state agencies, working together
to protect the healthcare trust funds through shared intelligence coordinated
enforcement, intended to enhance quality of care for program's beneficiaries.
Program is not called Senior Medicare Patrol SMP
They work to combat fraud and abuse.
SMP - Correct Answers -Senior Medicare Patrol
OIG - Correct Answers -Office of Inspector General
, AoA - Correct Answers -Administration on Aging
FCA - Correct Answers -False Claims Act
CMPL - Correct Answers -Civil Money Penalties Law
CMS Definition of Fraud - Correct Answers -knowingly making false statements or
misrepresenting facts to obtain an undeserved benefit or payment from a federal
healthcare program
CMS Definition of Abuse - Correct Answers -an action resulting in unnecessary costs to
a federal healthcare program either directly or indirectly
CMS Examples of Fraud - Correct Answers -Billing for Services/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 level higher than provided or necessary
Misrepresenting the diagnosis to justify payment
Making referrals to certain designated services that are prohibited
CMS Examples of Abuse - Correct Answers -Misusing codes on claims
Charging excessively for service 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
FCA - Correct Answers -Federal
False Claims Act
Lincoln Law - Correct Answers -False Claims Act, enacted 1863 to combat fraud from
suppliers of good to the Union Army during the Civil War
In 1943 amendments made it more difficult to bring action forward.
AND ANSWERS
Documentation states that the patient had a "Status post hysterectomy. The patient
presents with a fever." Which of the following would be a compliant question to query? -
Correct Answers -Do you know the cause of the fever?
Fraud - Correct Answers -Fraud is an intentional deception or misrepresentation of the
fact that can result in unauthorized benefits or payment. In this case, billing for services
at a higher level than provided would be considered intentional, and therefore
fraudulent.
When a provider is excluded under the Exclusions Statute, what must he or she do at
the end of the exclusionary period? - Correct Answers -The provider must apply for
reinstatement.
OIG has identified seven elements - Correct Answers -1-Implementing written policies,
procedures and standards of conduct;
2-Designating a compliance officer and/or compliance committee;
3-Conducting effective training and education;
4-Developing effective lines of communication;
5-Enforcing standards through well-publicized disciplinary guidelines;
6-Conducting internal monitoring and auditing; and
7-Responding promptly to detected offenses and developing corrective action
Operation Restore Trust - Correct Answers -3 offices were involved: OIG, Healthcare
Financing Administration, AoA
May 1995 Bill Clinton: 2 yr partnership of federal and state agencies, working together
to protect the healthcare trust funds through shared intelligence coordinated
enforcement, intended to enhance quality of care for program's beneficiaries.
Program is not called Senior Medicare Patrol SMP
They work to combat fraud and abuse.
SMP - Correct Answers -Senior Medicare Patrol
OIG - Correct Answers -Office of Inspector General
, AoA - Correct Answers -Administration on Aging
FCA - Correct Answers -False Claims Act
CMPL - Correct Answers -Civil Money Penalties Law
CMS Definition of Fraud - Correct Answers -knowingly making false statements or
misrepresenting facts to obtain an undeserved benefit or payment from a federal
healthcare program
CMS Definition of Abuse - Correct Answers -an action resulting in unnecessary costs to
a federal healthcare program either directly or indirectly
CMS Examples of Fraud - Correct Answers -Billing for Services/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 level higher than provided or necessary
Misrepresenting the diagnosis to justify payment
Making referrals to certain designated services that are prohibited
CMS Examples of Abuse - Correct Answers -Misusing codes on claims
Charging excessively for service 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
FCA - Correct Answers -Federal
False Claims Act
Lincoln Law - Correct Answers -False Claims Act, enacted 1863 to combat fraud from
suppliers of good to the Union Army during the Civil War
In 1943 amendments made it more difficult to bring action forward.
