CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 3

Question 1

Which regulation requires Medicare Part D plans to have a drug utilization management program?

Accepted Answer

42 CFR Part 423

Answer

42 CFR Part 423 governs the Medicare Prescription Drug Benefit (Part D) and includes requirements for drug utilization management programs.

Question 2

A patient advocate discovers that a Medicare plan is systematically denying claims for a medically necessary service. Which regulatory body should be notified first?

Accepted Answer

CMS or the State Insurance Commissioner

Answer

CMS has oversight authority over Medicare plans, and systemic denial issues should be reported to CMS or the applicable State Insurance Commissioner.

Question 3

What is 'balance billing' in the context of Medicare compliance?

Accepted Answer

When a provider charges a beneficiary more than Medicare's allowed amount

Answer

Balance billing occurs when a non-participating provider charges a beneficiary the difference between the provider's charge and Medicare's allowed amount, which is prohibited for most Medicare services.

Question 4

Under the Medicare Beneficiary Ombudsman role, which of the following is a core function?

Accepted Answer

Helping beneficiaries understand their rights and navigate appeals

Answer

The Medicare Beneficiary Ombudsman helps beneficiaries understand their rights, navigate complaints, and work through the appeals process.

Question 5

Which provision of the Affordable Care Act strengthened Medicare fraud enforcement by increasing civil monetary penalties?

Accepted Answer

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative

Answer

The HEAT initiative, strengthened under the ACA, brought together HHS and DOJ to enhance anti-fraud activities and imposed stiffer civil monetary penalties.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 3