CPMA STUDY Guide Questions with 100% Correct Answers | Verified | Updated 2023-2024, Exams of Advanced Education

Download CPMA STUDY Guide Questions with 100% Correct Answers | Verified | Updated 2023-2024 and more Exams Advanced Education in PDF only on Docsity! CPMA STUDY Guide Questions with 100% Correct Answers | Verified | Updated 2023-2024 WHAT IS THE IMPORTANCE OF AUDIT IN A PRACTICE? - Correct Answer-1. Reviewing quality of care provided to patients. 2. Educating providers on documentation. 3. Ensuring all services are supported and all appropriate revenue is captured. 4. Defending against external audit malpractice litigation and health plan request and denial. Exclusion Statute - Correct Answer-1.Physician is banned from participating in any federal or state healthcare program by OIG 2. They can't bill federal or state for any services provided .3 length: host less than five years .4 When exclusionary period has ended dr must apply for reinstatement and receive authorize notice from OIG that reinstate has been granted Abuse - Correct Answer-In action resulting in unnecessary cost to a federal healthcare program either directly or indirectly What is the civil penalty - Correct Answer-Not less than 5000 and not more than 10,000 per claim x3 times the amount of government damages Federal False Claims Act - Correct Answer-Having knowledge that claims is fake. .1 knowing and knowingly that a person must act in deliberate ignorance of the truth or falsely of the relevant information or act in a reckless manner of the truth or falsity of the Information Qui Tam - Correct Answer-whistleblower what percentage is offered for a whistleblower/qui tam as an award from what is recovered by the government? - Correct Answer-between 15% and 25% fraud - Correct Answer-Knowingly making false statements or misrepresenting facts to obtain an undeserved benefit or payment from federal healthcare program Discovery sample - Correct Answer-CIA - 50 samples units randomly selected *determines the net financial error rate .2 if error rate exceeds 5% a full sample must be reviewed HHS OIG 3 core publications - Correct Answer-1.work plan 2.semiannual report to congress 3. compendium unimplemented recommendation non-compliant conduct must be documented in compliance files & should include - Correct Answer-1. date of incident 2.name of the reporting party 3.name of the person responsible for taking action 4.the follow up the action taken What is an auditor - Correct Answer-Reviews healthcare providers policies add procedures to ensure compliance with applicable requirements cms uses what avenues to deliver Information - Correct Answer-1.webcasts 2. transmitting 3.manuals 4.the medicare learning network CIA Corporate Integrity Agreement - Correct Answer-Last five years can be longer if OIG likes OIG will require CIA as a condition for not seeking exclusion from participation when they seek to settle civil fraud cases requirements hearing compliance officer/ appointments compliance committee , employee training program,IRO (IRO) independent review organization - Correct Answer-(Third-party medical review resource) 1. Provides objective unbiased audits and reports. 2. OIG can notify provider within 30 days if IRO is unacceptable and may request IRO be terminated and another IRO be retained. Civil Monetary Penalties Law (CMP) - Correct Answer-(Improper filing of claims- Upcoding, miscoding) 1. Knowing it's a false claim. 2. Knowing Dr. is not licensed. 3. Changing DOS to when PT was effective with a government plan. 4. Knowing it's not medically necessary. *Penalties 10,000 to 50,000 per violation up to $22,363 for each item/service and 3X the amount improperly claimed. If disagree* can request hearing before an HHS administrative law judge. Anti-Kickback Law - Correct Answer-(Applies to anyone not just physicians) receiving cash or payment knowingly that it is illegal for referring people to doctor's office. *intent must be proven* $25,00 per violation - up to 5 years in prison (OIG) Office of Inspector General responsibilities - Correct Answer-To detect and prevent fraud, waste, abuse and violations of law, and to promote economy, efficiency and effectiveness in the operations of the federal government. (MUEs) medically unlikely edits - Correct Answer-Defined the maximum units of service that a provider would report under most circumstances for single beneficiary on a single date of service for a specific HCPCS/CPT code. When auditing EMR which of the following do you look for when reviewing documents? - Correct Answer-Complete medical histories on each visit, diagnosis driven by clinical pictures, repetitious notes not relevant to presenting problems State law will take precedence over HIPPA under what circumstance? - Correct Answer-If HIPPA is less restrictive than state law When providing a prescription for a patient the education of patients (i.e., side effects and supporting documentation) in the medical record that the information was reviewed is based on whose standards? - Correct Answer-Joint commission standard IRO reports audits to who? - Correct Answer-The compliance officer in the organization under the CIA Education and training to reinforce recommendation regarding physicians deficiencies and problematic areas is best addressed through - Correct Answer-Direct follow up with the physician When responding to subpoena for medical records what is not required to be copied and submitted? - Correct Answer-Signed authorization for release of information What would be considered good parameters for a baseline audit? - Correct Answer- Random audit of 10 to 15 records per practitioner What is/are the advantages of a peer review audit? - Correct Answer-Provides feedback among providers, clinical decision making can be addressed, coding accuracy Which type of audit often realizes more objectivity than with an employed auditor? - Correct Answer-External audit How often should an internal audit be conducted minimally? - Correct Answer-Annually An audit performed after the claims have been submitted is referred to as what type of audit? - Correct Answer-Retrospect audit Baseline audit - Correct Answer-An audit (usually random) of all possible services provided within a specific time frame, and is normally performed if documentation from various types of services needs to be reviewed Focused audit - Correct Answer-An audit that looks at one item, one type of service, or one provider. Necessary for deeper understanding of patterns of error or change in high risk areas or other areas of specific concerns To bill services incident to - - Correct Answer-The services must be as a result of the physicians treatment plan and must be in the office suite providing supervision. They do not need to be in the room but they must be in the office to be other services incident to. For example, a nurse administering an injection. If the physician is out of the office seeing patients at the hospital, the surfaces could not be billed because the physician is not providing supervision. Numerical sampling - Correct Answer-Based on all possible services within the chosen time frame; lends itself well to a random final selection Random audit - Correct Answer-all possible services within a specific time Frame. This type of audit is normally performed when an audit of the practice or the provider has never been performed also this audit will often identify areas for potential education and future focused audit to determine the effectiveness of education What should be the writing style of an audit report - Correct Answer-persuasive