CPMA Exam Prep 2023 with 100% correct answers

12.1% # of improper Medicare Fee-For-Service claim payments, according to Federal Government. FFS Fee-For-Service Prepayment Review Review of claims prior to payment. Prepayment reviews result in an initial determination. Postpayment Review 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 A payment a provider receives under the amount due for services furnished under the Medicare statute and regulations. Overpayment A payment a provider receives over the amount due for services furnished under Medicare statutes and regulations 5 Common reasons for overpayment are: *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 Medicare Administrative Contractors MAC Responsibilities 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 Zone Program Integrity Contractors PSCs Program Safeguard Contractor ZPICs/PSCs 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 Supplemental Medical Review Contractor SMRC Responsibilities Conduct nationwide medical review as directed by CMS (includes identifying underpayments and overpayments Medicare FFS Recovery Auditors Review claims to identify potential underpayments and overpayments in Medicare FFS, as part of the Recovery Audit Program