CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 2

Question 1

Under the Medicare Advantage regulations, what is the maximum number of days a plan has to resolve a standard coverage determination request?

Accepted Answer

7 calendar days

Answer

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?

Accepted Answer

The Anti-Kickback Statute

Answer

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?

Accepted Answer

Submit a Redetermination request to the plan or contractor

Answer

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?

Accepted Answer

To prevent, detect, and correct non-compliance with CMS requirements

Answer

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?

Accepted Answer

Office of Inspector General (OIG)

Answer

The Office of Inspector General (OIG) of HHS is the primary agency responsible for investigating Medicare and Medicaid fraud, waste, and abuse.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 2