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CPMA Exam Questions and Answers (100% Pass)
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CMS Fraud Definition Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program CMS Abuse Definition An action that results in unnecessary costs to a federal healthcare program, either directly or indirectly CMS Examples o...

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  • October 18, 2024
  • 203
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • cpma exam questions and answers 100 pass

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  • CPMA
  • CPMA

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1 | P a g e | © copyright 2024/2025 | Grade A+




CPMA Exam Questions and
Answers (100% Pass)
CMS Fraud Definition


✓ Making false statements or misrepresenting facts to obtain an

undeserved benefit or payment from a federal healthcare program




CMS Abuse Definition


✓ An action that results in unnecessary costs to a federal healthcare

program, either directly or indirectly




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




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✓ 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




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

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✓ 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 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


✓ 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.




List of Excluded Individuals/Entities (LEIE)




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