CPMA Exam
CMS Fraud Definition *** Making false statements or misrepresenting facts to obtain an undeserved
benefit or payment from a federal healthcare program
CMS Abuse Definition *** An action that results in unnecessary costs to a federal healthcare program,
either directly or indirectly
CMS Examples of Fraud *** 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 *** 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 *** 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 *** $5,500-$11,000 per claim
When does the False Claims Act allow for reduced penalties? *** 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 *** 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 *** 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 *** 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 *** Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law *** 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 *** 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) *** 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 *** 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 *** 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 *** 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 *** 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 *** 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) *** 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 *** 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? *** 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 *** 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 *** 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) *** 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? *** 50
Purpose of a Discovery Sample *** Used to determine the net financial error rate; if the error rate
exceeds 5%, a Full Sample must be reviewed, along with a Systems Review
What is the name of the statistical sampling program provided by the OIG to randomly select and
determine the size of the Discovery Sample? *** RAT-STATS
What percent of precision and confidence are required to estimate the overpayment? *** 90%
confidence and 25% precision level
CMS Fraud Definition *** Making false statements or misrepresenting facts to obtain an undeserved
benefit or payment from a federal healthcare program
CMS Abuse Definition *** An action that results in unnecessary costs to a federal healthcare program,
either directly or indirectly
CMS Examples of Fraud *** 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 *** 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 *** 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 *** $5,500-$11,000 per claim
When does the False Claims Act allow for reduced penalties? *** 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 *** 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 *** 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 *** 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 *** Up to $25,000 fine and/or imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law *** 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 *** 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) *** 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 *** 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 *** 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 *** 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 *** 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 *** 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) *** 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 *** 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? *** 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 *** 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 *** 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) *** 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? *** 50
Purpose of a Discovery Sample *** Used to determine the net financial error rate; if the error rate
exceeds 5%, a Full Sample must be reviewed, along with a Systems Review
What is the name of the statistical sampling program provided by the OIG to randomly select and
determine the size of the Discovery Sample? *** RAT-STATS
What percent of precision and confidence are required to estimate the overpayment? *** 90%
confidence and 25% precision level
