CMS Medicare Specialist Fraud, Waste & Abuse Prevention 2

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:

Accepted Answer

A specific exception applies under the law

Answer

The patient gives written consent to the referral

Answer

The service is not covered by Medicare Part A

Answer

The physician discloses the relationship to the state medical board

Question 2

What is a 'qui tam' lawsuit in the context of the False Claims Act?

Accepted Answer

A lawsuit filed by a private individual (whistleblower) on behalf of the government

Answer

A government-initiated criminal prosecution of a Medicare provider

Answer

A civil administrative action taken by a Medicare Administrative Contractor

Answer

A class action lawsuit filed by Medicare beneficiaries against a provider

Question 3

Which of the following is an example of Medicare fraud (as opposed to abuse or waste)?

Accepted Answer

A provider billing for services never rendered to receive Medicare reimbursement

Answer

A provider billing for a slightly higher level E/M code due to poor documentation

Answer

A provider overordering supplies due to poor inventory management

Answer

A provider submitting a claim with an incorrect modifier due to coder error

Question 4

What does the term 'unbundling' refer to in Medicare billing fraud?

Accepted Answer

Billing separately for services that should be billed together under one comprehensive code

Answer

Separating a covered service from a non-covered service on a single claim

Answer

Combining multiple patient records into one fraudulent claim

Answer

Billing Medicare and Medicaid simultaneously for the same service

Question 5

CMS's Zone Program Integrity Contractors (ZPICs) are primarily responsible for which function?

Accepted Answer

Identifying and investigating potential fraud, waste, and abuse in Medicare claims

Answer

Processing Medicare claims and adjudicating appeals

Answer

Setting reimbursement rates for Medicare-covered services

Answer

Auditing Medicare Advantage plan enrollment data

Question 6

Under the Civil Monetary Penalties Law (CMPL), what is the maximum civil monetary penalty per false claim submitted to Medicare?

Accepted Answer

$11,000

Answer

$5,000

Answer

$25,000

Answer

$50,000

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:

Accepted Answer

Potentially abusive billing practices that may warrant review

Answer

Fraud, because documentation is always required

Answer

A coding error that requires immediate criminal referral

Answer

Standard billing variation within normal provider patterns