CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 5

Question 1

What is the 'two-midnight rule' and how does it affect Medicare compliance?

Accepted Answer

A benchmark for determining whether a hospital admission should be billed as inpatient or outpatient

Answer

The two-midnight rule states that inpatient admission is appropriate when the physician expects the patient to require care spanning at least two midnights; shorter stays are generally billed as outpatient.

Question 2

A Medicare Specialist is helping a dual-eligible beneficiary (Medicare and Medicaid) understand their benefits. Which program coordinates their benefits?

Accepted Answer

Medicare-Medicaid Plans (MMPs) or Dual Eligible Special Needs Plans (D-SNPs)

Answer

Medicare-Medicaid Plans and Dual Eligible Special Needs Plans are specifically designed to coordinate benefits for individuals who qualify for both Medicare and Medicaid.

Question 3

Under the False Claims Act, what is the minimum civil penalty per false claim submitted to Medicare?

Accepted Answer

Over $13,000 (adjusted for inflation)

Answer

The False Claims Act imposes civil penalties per false claim that are adjusted for inflation; as of recent years, the minimum exceeds $13,000 per false claim.

Question 4

What is the role of a Medicare Administrative Contractor (MAC) in the compliance framework?

Accepted Answer

They process Medicare Part A and Part B fee-for-service claims and conduct medical reviews

Answer

Medicare Administrative Contractors process fee-for-service claims, conduct medical reviews, provide education to providers, and handle redeterminations for Parts A and B.

Question 5

Which patient rights provision requires Medicare providers to give patients an Advance Beneficiary Notice (ABN)?

Accepted Answer

When a provider believes Medicare will deny payment for a service as not medically necessary or not covered

Answer

An ABN must be given to beneficiaries before providing a service when the provider reasonably believes Medicare will deny payment, allowing the patient to decide whether to receive and pay for the service.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Regulatory Compliance & Patient Advocacy 5