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CPCO Chapter 11 EXAM - RACs, ZPICs, MICs,
PSCs, MFCUs Questions and Verified Answers
Can providers request an extension to provide 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?
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Ans: Billing under several NPI's at a time
Response Feedback:
Double billing, billing for services not rendered and billing for more than 24
hours in a day are all typical ways that providers attempt fraud. (Billing for
time not spent with a patient}.
Who cannot be a violator of fraud?
Ans: Anyone can be a violator of fraud
Response Feedback:
A violator may be a provider, a beneficiary, or an employee of a provider or
some other business entity; basically anyone.
The ______________ was signed into law which required CMS to use competitive
procedures to replace its current fraud inspections and carriers with a uniform
type of administrative entity, referred to as Medicare administrative contractors
(MAC).
Ans: The ______________ was signed into law which required CMS to use
competitive procedures to replace its current fraud inspections and carriers
with a uniform type of administrative entity, referred to as Medicare
administrative contractors (MAC).
Medicare Modernization Act (MMA)
Ans: Response Feedback:
Medicare Modernization Act (MMA). On December 8, 2003, the Medicare
Modernization Act (MMA) was signed into law. This required CMS to use
competitive procedures to replace its current fraud inspections and carriers
with a uniform type of administrative entity, referred to as Medicare
administrative contractors (MAC).
John is the Compliance Officer for ABC Medical Group. He is explaining to a
group of providers the many types of acronyms that are associated with
healthcare compliance. A provider asks John what the acronym MIP refers to. The
answer is:
CPCO Chapter 11 EXAM - RACs, ZPICs, MICs,
PSCs, MFCUs Questions and Verified Answers
Can providers request an extension to provide 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?
, Page | 3
Ans: Billing under several NPI's at a time
Response Feedback:
Double billing, billing for services not rendered and billing for more than 24
hours in a day are all typical ways that providers attempt fraud. (Billing for
time not spent with a patient}.
Who cannot be a violator of fraud?
Ans: Anyone can be a violator of fraud
Response Feedback:
A violator may be a provider, a beneficiary, or an employee of a provider or
some other business entity; basically anyone.
The ______________ was signed into law which required CMS to use competitive
procedures to replace its current fraud inspections and carriers with a uniform
type of administrative entity, referred to as Medicare administrative contractors
(MAC).
Ans: The ______________ was signed into law which required CMS to use
competitive procedures to replace its current fraud inspections and carriers
with a uniform type of administrative entity, referred to as Medicare
administrative contractors (MAC).
Medicare Modernization Act (MMA)
Ans: Response Feedback:
Medicare Modernization Act (MMA). On December 8, 2003, the Medicare
Modernization Act (MMA) was signed into law. This required CMS to use
competitive procedures to replace its current fraud inspections and carriers
with a uniform type of administrative entity, referred to as Medicare
administrative contractors (MAC).
John is the Compliance Officer for ABC Medical Group. He is explaining to a
group of providers the many types of acronyms that are associated with
healthcare compliance. A provider asks John what the acronym MIP refers to. The
answer is:
