EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024.
CPMA Exam Study Guide with Complete
Solutions
CMS Fraud Definition - Answer✔✔-Making false statements or misrepresenting facts to obtain
an undeserved benefit or payment from a federal healthcare program
CMS Abuse Definition - Answer✔✔-An action that results in unnecessary costs to a federal
healthcare program, either directly or indirectly
CMS Examples of Fraud - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-$5,500-$11,000 per claim
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When does the False Claims Act allow for reduced penalties? - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-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
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Penalty for violating the Anti-Kickback Law - Answer✔✔-Up to $25,000 fine and/or
imprisonment of up to 5 years
Stark Law vs. Anti-Kickback Law - Answer✔✔-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 - Answer✔✔-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) - Answer✔✔-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 - Answer✔✔-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
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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 - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-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 - Answer✔✔-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
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