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CPMA Compliance and Regulatory Guidelines (Ch 1) Q&A
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CPMA Compliance and Regulatory Guidelines (Ch 1) Q&A
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CPMA Compliance and Regulatory Guidelines (Ch 1)Q&A 2023-2024
Quiz :Operation Restore Trust (ORT) - Answer :* Two year partnership of
federal and state agencies working together to protect the healthcare trust
fund through shared intelligence and coordinated enforcement
* Three agencies involved: The Office of the Inspector General (OIG), the
Health Care Financing Administration (now CMS), and the Administration on
Aging (AoA).
* Program is now called Senior Medicare Patrol (CMP) with the HHS, CMS, and
OIG working together to combat fraud and abuse.
Quiz :Fraud - Answer :* CMS defines as knowingly making false statements or
misrepresenting facts to obtain an undeserved benefit or payment from a
federal health care plan.
* Intentional
* Examples include:
1) Billing for services and/or supplies that you know were not furnished or
provided.
2) Altering claim forms and/or receipts to receive a higher payment amount.
3) Billing for services at a higher level than provided or necessary.
4) Misrepresenting the diagnosis to justify payment.
5) Making referrals for certain designated services that are prohibited.
Quiz :Abuse - Answer :* CMS defines as an action resulting in unnecessary
costs to a federal healthcare program, either directly or indirectly.
* Unnecessary costs
* Examples include:
1) Misusing codes on a claim.
2) Charging excessively for services or supplies.
3) Billing for services that were not medically necessary.
4) Failure to maintain adequate medical or financial records.
5) Improper billing practices.
6) Billing Medicare patients a higher fee schedule than non-Medicare patients.
Quiz :Federal False Claims Act (FCA) Part 1 - Answer :* Also called the Lincoln
Law.
* Enacted in 1863 to combat fraud by suppliers of goods to the Union Army
during the US Civil War. (Defective weapons, selling sick horses or selling the
same animal more than once.)
, * Defines seven (7) situations where the person is liable including:
1) Knowingly present, or causes to be presented, a false or fraudulent claim for
payment or approval.
2) Knowling makes, uses, or causes to be made or used, a false record or
statement material to a false or fraudulent claim.
3) Conspires to commit a violation of any of the others.o
4) Has possession, custody, or control of property or money used, or to be
used, by the government and knowingly delivers, or causes to be delivered,
less than all of that money or property.
5) Is authorized to make or deliver a document certifying receipt of property
used, or to be used, by the government and, intended to defraud the
government, make or delivers the receipt without completely knowing that the
information on the receipt is true.
6) Knowingly buys, or receives as a pledge of an obligation or debt, public
property from an officer or employee of the government, or a member of the
Armed Forces, who lawfully may not sell or pledge property.
7) Knowingly makes, uses, or causes to be made or used, a false record or
statement material to an obligation to pay or transmit money or property to
the government, or knowingly conceals or knowingly and improperly avoids or
decreases an obligation to pay or transmit money or property to the
government.
Quiz :Federal False Claims Act (FCA) Part 2 - Answer :** Healthcare services
subject to the False Claims Act include:
1) Falsifying a medical chart notation.
2) Submitting claims for services not performed, not requested, or
unnecessary.
3) Submitting claims for expired drugs.
4) Upcoding and/or unbundling services.
5) Submitting claims for physician services performed by a non-physician
provider (NPP) without regard to incident-to guidelines.
* FCA is violated by submitting a false claim WITH KNOWLEDGE THAT IT IS
FALSE even if there is no intent to defraud.
* Cost of Violation:
1) $10,781 to $21,563 per claim, plus three times the amount of damages to
the government.
2) Penalties can be reduced if the person self-discloses and:
a) provides all information within 30 days,
b) fully cooperates with the investigation, and
c) no action has commenced and no actual knowledge was present.
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