CPMA Exam All Answers Correct
1. What is defined as CMS fraud?
A) Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a
federal healthcare program
B) An action that results in unnecessary costs to a federal healthcare program, either directly or ...
CPMA Exam All Answers Correct
1. What is defined as CMS fraud?
A) Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a
federal healthcare program
B) An action that results in unnecessary costs to a federal healthcare program, either directly or
indirectly
C) A type of billing error that occurs when a healthcare provider accidentally submits an incorrect claim
D) A form of healthcare fraud committed by patients who intentionally misrepresent their medical
conditions to obtain benefits
Correct answer: A) Making false statements or misrepresenting facts to obtain an undeserved benefit or
payment from a federal healthcare program
2. What is an example of CMS abuse?
A) Billing for services and/or supplies that were not furnished or provided
B) Providing high-quality patient care without considering the cost
C) Charging excessively for services or supplies
D) Conducting regular quality control checks on healthcare providers
Correct answer: A) Billing for services and/or supplies that were not furnished or provided
3. What is the purpose of the False Claims Act?
A) To punish individuals who commit Medicare fraud
B) To encourage individuals to report Medicare fraud
C) To provide a mechanism for healthcare providers to appeal denied claims
D) To eliminate Medicare fraud
,Correct answer: B) To encourage individuals to report Medicare fraud
4. What is the penalty for violating the False Claims Act?
A) Up to $5,500 per claim
B) Up to $11,000 per claim
C) Up to $25,000 per claim
D) Up to $50,000 per claim
Correct answer: B) Up to $11,000 per claim
5. When can penalties be reduced under the False Claims Act?
A) If the person committing the violation does not cooperate with the investigation
B) If the person committing the violation self-discloses and provides all known information within 30
days, fully cooperates with the investigation, and there is no criminal prosecution, civil action, or
administrative action regarding the violation
C) If the person committing the violation has a prior criminal record
D) If the person committing the violation has a history of good behavior
Correct answer: B) If the person committing the violation self-discloses and provides all known
information within 30 days, fully cooperates with the investigation, and there is no criminal prosecution,
civil action, or administrative action regarding the violationList 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
Amount of civil monetary penalties ✔️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 ✔️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 ✔️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 ✔️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 mutual funds (services furnished by a rural
provider); exceptions related to other compensation arrangements (personal services arrangements and
rental of office space and equipment)
Office of the Inspector General (OIG) ✔️Detects and prevents fraud, waste, and abuse and improves
efficiency of HHS programs; most resources are directed toward the oversight of Medicare and
Medicaid, but also extend to the Centers for Disease Control and Prevention (CDC), National Institutes of
Health (NIH), and the Food and Drug Administration (FDA)
OIG Work Plan ✔️Published annually; lists the various projects that will be addressed during the fiscal
year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and
Office of Counsel to the Inspector General; summarizes new and ongoing reviews and activities that OIG
plans to pursue during the next fiscal year and beyond
Why should an auditor know what is in the OIG Work Plan for the current year? ✔️It allows an auditor
to inform providers and facilities of services or issues of which to be especially mindful in the coming
, year; may be helpful in forming the scope of an audit for a provider or facility or may influence
recommendations given to a practice
Corporate Integrity Agreements ✔️Required by the OIG s a condition of not seeking exclusion from
participation when an individual or entity seeks to settle civil healthcare fraud cases; typically last 5 yrs
but can be longer; most have the same core requirements along with specific steps for the individual or
entity that are related to the conduct that led to the settlement
Core requirements in CIAs ✔️Hiring a compliance officer/appointing a compliance committee;
developing written standards and policies; implementing a comprehensive employee training program;
retaining an independent review organization (IRO) to conduct annual reviews; establishing a
confidential disclosure program; restricting employment of ineligible persons; reporting overpayments,
reportable events, and ongoing investigations/legal proceedings; providing an implementation report
and annual reports to the OIG on the status of the entity's compliance activities
Independent review organization (IRO) ✔️Acts as a 3rd party medical review resource that provides
objective, unbiased audits and reports
How many sampling units are selected for review in a Discovery Sample under a CIA? ✔️50
Purpose of a Discovery Sample ✔️Used to determine the net financial error rate; if the error rate
exceeds 5%, a Full Sample must be reviewed, along with a Systems Review
What is the name of the statistical sampling program provided by the OIG to randomly select and
determine the size of the Discovery Sample? ✔️RAT-STATS
What percent of precision and confidence are required to estimate the overpayment? ✔️90%
confidence and 25% precision level
Certificate of Compliance Agreement (CCA) ✔️Require the provider to certify that is will continue to
operate its existing compliance programs and to report to OIG for a lesser period of time (usually 3
years); introduced in Inspector General Janet Rehnquist's An Open Letter to Healthcare Providers in
November 2011
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