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1) The CMS Improper Payment Data Report is based on audit findings from what type of CMS Audit?
C: CERT (Comprehensive Error Rate Testing)
Rational:
The CMS Improper Payment Data Report comes from the findings of the Comprehensive Error Rate Testing (CERT) program. This program checks how accurate Medicare payments are by looking at a random selection of claims to find out how often payments are made incorrectly. The results help create the annual Medicare Fee-for-Service improper payment rate, which is shared in the HHS Agency Financial Report.
Why Not the Other Options?
TPE (Targeted Probe and Education) – This program focuses on educating providers about specific claim mistakes but does not provide data for the Improper Payment Report.
UPIC (Unified Program Integrity Contractor) – This group looks into fraud, waste and abuse rather than reporting on improper payment rates.
RAC (Recovery Audit Contractor) – This contractor finds and retrieves incorrect payments but does not calculate the overall improper payment rate statistically.
2) The overpayment lookback period for CMS is:
C: 6 years
Rational:
Under 42 CFR § 401.305, CMS requires providers and suppliers to report and return overpayments within 60 days of identifying them. Additionally, the regulation states that the lookback period for identifying and reporting overpayments is 6 years from the date the overpayment was received.
3) When providers/organizations enter into a Corporate Integrity Agreement with the OIG, they agree to meet the obligations, and in exchange, the OIG agrees not to seek their EXCLUSION from participation in Medicare, Medicaid, or other Federal health care programs.
Rational:
A Corporate Integrity Agreement (CIA) is a formal agreement between a healthcare provider or organization and the Office of Inspector General (OIG). This agreement usually comes after an investigation into issues like fraud or waste concerning federal healthcare programs like Medicare or Medicaid.
When a provider or organization signs a CIA, they agree to follow certain rules to ensure they don’t break any laws again. These rules could include things like regular checks on their operations, training their staff, and having independent reviews of their practices. In return, the OIG won’t prevent them from getting payments from federal healthcare programs. If a provider agrees to enter into a CIA, the OIG agrees not to seek their exclusion from participation from federal healthcare programs during the time of the agreement.
Why does this matter? If a provider is excluded from federal healthcare programs, they can’t bill Medicare, Medicaid or similar programs, which can seriously impact their finances. A CIA lets them stay involved in these programs while showing that they are following the rules set by the OIG and CMS.
Most CIAs last for five years and include requirements for ongoing monitoring and reporting. So, when it comes to the agreement, the key point is “exclusion,” because the OIG promises not to bar the provider or organization from federal healthcare programs as long as they keep their commitments under the CIA.
4) The following elements are included in a Corporate Integrity Agreement:
E: All of the above
Rational:
A Corporate Integrity Agreement (CIA) is a formal agreement created between a healthcare provider and the Office of Inspector General (OIG) to address concerns about fraud, waste or abuse. This agreement sets out rules that the provider needs to follow to keep participating in Medicare, Medicaid and other government health programs.
Here are some important parts of a CIA:
1. **Hiring a Compliance Officer/Committee** – The organization must appoint a Compliance Officer or form a Compliance Committee to oversee and ensure that they are following the CIA and sticking to regulations.
2. **Developing Written Standards and Policies** – The provider needs to create and keep written rules and procedures that help them comply with the requirements of federal health programs.
3. **Retaining an Independent Review Organization (IRO)** – An outside organization must be brought in to conduct yearly reviews to check if the provider is meeting the obligations set by the CIA.
5) The typical sample size for a Target, Probe and Educate audit is:
D: 20-40
Rational:
Targeted Probe and Educate (TPE) audits are carried out by Medicare Administrative Contractors (MACs) to find and fix mistakes in payments by providing specific education to healthcare providers. These audits follow a clear, three-step process and focus on healthcare providers who have high error rates or billing habits that are unusual compared to others.
In each round of the review, the MAC usually looks at 20 to 40 claims from each provider, either before payments are made or after they have been made. If mistakes are found, the MAC offers training and advice to help the provider improve their documentation and billing methods. If mistakes continue after three rounds, the provider may be sent to the Centers for Medicare & Medicaid Services (CMS) for further audits or actions to take.
Why Not the Other Options?
Therefore, the correct answer is “d. 20-40,” as this is the standard number of claims reviewed in TPE audits by MACs.
6) The top root cause for improper payments related to lab services in the 2024 Improper Payment report is Insufficient Documentation.
Rational:
The 2024 Improper Payment Report identifies insufficient documentation as the top root cause for improper payments related to lab services. This means that in many cases, lab service claims lack the necessary supporting documentation to justify the services provided. Here’s why this is significant:
Understanding that insufficient documentation is the primary issue helps healthcare organizations focus on improving their record-keeping and billing practices to reduce audit findings and enhance compliance.
7) Emergency Room Visits have an overall improper payment rate of what percentage in the 2024 CMS Improper Payment Data report:
B: 11%
Rational:
According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data released by the Centers for Medicare & Medicaid Services (CMS), emergency room visits have an improper payment rate of 11.0%.
This statistic indicates that out of all claims submitted for emergency room services, 11% were found to have errors leading to improper payments. Understanding this rate is crucial for healthcare providers, as it highlights the need for accurate documentation and billing practices to reduce errors and ensure compliance with Medicare guidelines.
By focusing on the specific improper payment rate for emergency room visits, providers can implement targeted strategies to address common issues, thereby improving the quality of claims and reducing the likelihood of payment denials or recoupments.
8) The primary purpose of a UPIC audit is to:
C: Identify potentially fraudulent billing that could indicate fraud, waste and abuse.
Rational:
A UPIC audit is done by contractors working for CMS to find and look into possible fraud, waste and abuse in Medicare and Medicaid.
Why UPIC Audits Are Done:
UPICs check claims data and search for signs of fraud, like billing for services that weren’t actually provided, charging for a more expensive service than what was given, breaking apart related services into separate claims, or overusing certain services. These audits may involve visiting providers, talking to them, and reviewing medical records to see if any improper billing practices are happening. If fraud is found, UPICs may report it to law enforcement for further actions, such as fines or criminal charges.
In summary, the main goal of a UPIC audit is to find potentially fraudulent billing practices and help protect federal healthcare programs.
9) When should a provider consider using the CMS Self-Disclosure Protocol?
B: When the provider identifies potential violations of Stark Law or Anti-Kickback Statute
Rational:
The CMS Self-Referral Disclosure Protocol (SRDP) allows healthcare providers to voluntarily disclose potential violations of the Stark Law (also known as the Physician Self-Referral Law) to CMS. Additionally, the OIG’s Self-Disclosure Protocol (SDP) provides a mechanism for providers to disclose potential violations of the Anti-Kickback Statute (AKS) and other federal health program offenses.
When Should a Provider Use the Self-Disclosure Protocol?
• If a provider identifies a potential Stark Law violation (e.g., non-compliant physician compensation arrangements, improper referrals).
• If there is a possible Anti-Kickback Statute violation, such as illegal remuneration in exchange for patient referrals.
• Self-disclosure may result in reduced penalties compared to enforcement action initiated by CMS or the OIG.
10) The main focus of RAC (Recovery Audit Contractor) audits is to:
B: Identify and recover improper Medicare and Medicaid payments
Rational:
RAC audits are conducted by contractors working for CMS to find and recover incorrect payments made to healthcare providers. These audits look at overpayments caused by mistakes in billing, lack of proper paperwork, and questions about whether services were actually needed, as well as underpayments. Unlike UPIC audits, which investigate fraud, waste and abuse, RAC audits mainly focus on checking that Medicare and Medicaid claims are billed accurately.
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