CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 2 — Questions and Answers
Question 1: Under the Medicare Advantage regulations, what is the maximum number of days a plan has to resolve a standard coverage determination request?
- 3 calendar days
- 7 calendar days (Correct answer)
- 14 calendar days
- 30 calendar days
Correct answer: 7 calendar days
Medicare Advantage plans must resolve standard coverage determinations within 7 calendar days of receiving the request.
Question 2: Which federal law prohibits Medicare providers from offering inducements to beneficiaries that could influence their healthcare decisions?
- HIPAA
- The Anti-Kickback Statute (Correct answer)
- The Stark Law
- The False Claims Act
Correct answer: The Anti-Kickback Statute
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals or the generation of business covered by federal healthcare programs.
Question 3: A Medicare beneficiary believes their plan wrongly denied a claim. What is the FIRST formal step in the Medicare appeals process?
- File a complaint with the State Insurance Commissioner
- Submit a Redetermination request to the plan or contractor (Correct answer)
- Request an Administrative Law Judge hearing
- Contact the Medicare ombudsman
Correct answer: Submit a Redetermination request to the plan or contractor
The first level of the Medicare appeals process is a Redetermination, which must be submitted to the plan or Medicare Administrative Contractor that made the initial determination.
Question 4: What is the primary purpose of the Medicare Compliance and Ethics Program required for Medicare Advantage organizations?
- To maximize plan enrollment
- To prevent, detect, and correct non-compliance with CMS requirements (Correct answer)
- To reduce beneficiary premiums
- To streamline prior authorization processes
Correct answer: To prevent, detect, and correct non-compliance with CMS requirements
Compliance and ethics programs are designed to prevent, detect, and correct non-compliance with CMS requirements and fraudulent or abusive conduct.
Question 5: Which government agency is primarily responsible for investigating Medicare fraud and abuse cases?
- Office of Inspector General (OIG) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- Department of Labor (DOL)
- Federal Trade Commission (FTC)
Correct answer: Office of Inspector General (OIG)
The Office of Inspector General (OIG) of HHS is the primary agency responsible for investigating Medicare and Medicaid fraud, waste, and abuse.
Question 6: What does the term 'upcoding' refer to in Medicare billing compliance?
- Adding modifier codes to claims
- Billing for a higher level of service than was actually provided (Correct answer)
- Correcting coding errors on previously submitted claims
- Using electronic billing systems
Correct answer: Billing for a higher level of service than was actually provided
Upcoding is the fraudulent practice of billing for a more expensive service or procedure than was actually performed.
Question 7: A Medicare Specialist advocates for a beneficiary who needs an expedited appeal. What is the maximum timeframe for a plan to respond to an expedited coverage determination for a Medicare Advantage plan?
- 24 hours
- 48 hours
- 72 hours (Correct answer)
- 5 business days
Correct answer: 72 hours
Medicare Advantage plans must respond to expedited coverage determination requests within 72 hours when a standard timeframe could seriously jeopardize the enrollee's life or health.
CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 2
Under the Medicare Advantage regulations, what is the maximum number of days a plan has to resolve a standard coverage determination request?