CPMA EXAM QUESTIONS AND ANSWERS

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 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 re