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CPMA Exam Questions And Answers 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 serv...

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  • October 19, 2024
  • 180
  • 2024/2025
  • Exam (elaborations)
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CPMA
Exam Questions And Answers

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

, CPMA
Exam Questions And Answers
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

, CPMA
Exam Questions And Answers
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.

, CPMA
Exam Questions And Answers
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

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