CMS Medicare Specialist Fraud, Waste & Abuse Prevention 2 — Questions and Answers
Question 1: The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring Medicare patients to entities in which they have a financial relationship unless:
- The patient gives written consent to the referral
- A specific exception applies under the law (Correct answer)
- The service is not covered by Medicare Part A
- The physician discloses the relationship to the state medical board
Correct answer: A specific exception applies under the law
The Stark Law prohibits physician self-referrals unless a specific statutory or regulatory exception applies, such as the in-office ancillary services exception.
Question 2: What is a 'qui tam' lawsuit in the context of the False Claims Act?
- A government-initiated criminal prosecution of a Medicare provider
- A lawsuit filed by a private individual (whistleblower) on behalf of the government (Correct answer)
- A civil administrative action taken by a Medicare Administrative Contractor
- A class action lawsuit filed by Medicare beneficiaries against a provider
Correct answer: A lawsuit filed by a private individual (whistleblower) on behalf of the government
A qui tam lawsuit allows a private individual (relator or whistleblower) to file a lawsuit on behalf of the government and potentially receive a portion of any recovered funds.
Question 3: Which of the following is an example of Medicare fraud (as opposed to abuse or waste)?
- A provider billing for a slightly higher level E/M code due to poor documentation
- A provider billing for services never rendered to receive Medicare reimbursement (Correct answer)
- A provider overordering supplies due to poor inventory management
- A provider submitting a claim with an incorrect modifier due to coder error
Correct answer: A provider billing for services never rendered to receive Medicare reimbursement
Billing for services never rendered is a clear example of fraud because it involves a knowing and intentional misrepresentation made to obtain Medicare payment.
Question 4: What does the term 'unbundling' refer to in Medicare billing fraud?
- Separating a covered service from a non-covered service on a single claim
- Billing separately for services that should be billed together under one comprehensive code (Correct answer)
- Combining multiple patient records into one fraudulent claim
- Billing Medicare and Medicaid simultaneously for the same service
Correct answer: Billing separately for services that should be billed together under one comprehensive code
Unbundling is the practice of billing multiple component codes separately instead of using a single comprehensive code that covers all services, resulting in higher reimbursement.
Question 5: CMS's Zone Program Integrity Contractors (ZPICs) are primarily responsible for which function?
- Processing Medicare claims and adjudicating appeals
- Identifying and investigating potential fraud, waste, and abuse in Medicare claims (Correct answer)
- Setting reimbursement rates for Medicare-covered services
- Auditing Medicare Advantage plan enrollment data
Correct answer: Identifying and investigating potential fraud, waste, and abuse in Medicare claims
ZPICs conduct investigations of potential fraud, waste, and abuse in Medicare and Medicaid programs, coordinating with law enforcement when criminal activity is suspected.
Question 6: Under the Civil Monetary Penalties Law (CMPL), what is the maximum civil monetary penalty per false claim submitted to Medicare?
- $5,000
- $11,000 (Correct answer)
- $25,000
- $50,000
Correct answer: $11,000
Under the CMPL, OIG can impose penalties of up to approximately $11,000 per false claim (adjusted for inflation), plus up to three times the amount fraudulently claimed.
Question 7: A Medicare Specialist notices a pattern of claims for a service that is covered only under specific circumstances being billed without supporting documentation. This is best classified as:
- Fraud, because documentation is always required
- Potentially abusive billing practices that may warrant review (Correct answer)
- A coding error that requires immediate criminal referral
- Standard billing variation within normal provider patterns
Correct answer: Potentially abusive billing practices that may warrant review
Without evidence of intent, a pattern of billing without supporting documentation is most accurately characterized as potentially abusive and warrants review and corrective action before escalating to fraud.
CMS Medicare Specialist Fraud, Waste & Abuse Prevention 2
The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring Medicare patients to entities in which they have a financial relationship unless: