Chapter 1 CPMA Exam Prep (100% Correct Answers)

12.1% correct answers # of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS correct answers Fee-For-Service Prepayment Review correct answers Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review correct answers Review of claims after payment. May result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment. Underpayment correct answers A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment correct answers A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: correct answers *Billing for excessive and subsequent payment of the same service or claim. *Duplicate submission and payment for same service or claim *Payment for excluded or Medically unnecessary services. *Payment for services in setting not appropriate to pt's needs or condition *Payment to an incorrect payee. MACs correct answers Medicare Administrative Contractors MAC Responsibilities correct answers Process claims from physicians, hospitals, and other health care professionals, and submit payment to those providers according to Medicare rules and regulations (including identifying under- and overpayments). ZPICs correct answers Zone Program Integrity Contractors PSCs correct answers Program Safeguard Contractor ZPICs/PSCs correct answers Perform investigations that are unique and tailored to specific circumstances and occur only in situations where there is potential fraud, and take appropriate corrective actions SMRC correct answers Supplemental Medical Review Contractor SMRC Responsibilities correct answers Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments