CPMA Analysis and Communications Practice Test

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• What best describes the audit scope?
• Which statement best describes an Independent Review Organization's (IRO) obligation regarding corrective actions?
• How are errors identified in an annual audit treated in subsequent internal audits?
• If the cause of error is misunderstanding on the part of entity's coding and billing personnel, what may be necessary?
• Which guideline best describes oral communication during an audit?
• Typically, how long is a Corporate Integrity Agreement (CIA) in effect?
• What information about sampling should be disclosed in an audit report?
• Under circumstances where the NCCI manual instructs that a Column 1 code is not reportable with a Column 2 code, what risk occurs if both services are paid?
• The audit report should be kept as brief as possible.
• In the context of NCCI, under what condition does reporting an exclusionary modifier permit separate payment?
• Which statement describes the role of the sampling approach in audits when 100 percent review isn't feasible?
• What should accompany audit findings to be actionable?
• Under CIA, may an IRO explain the basis for audit results and the perceived cause of any declared error?
• Which statement correctly describes the use of SDP and SDRP for Stark Law and AKS violations?
• Are Internet Only Manuals (IOMs) published by CMS and LCDs published by MACs laws?
• If a controlling standard does not exist for the service being evaluated, what should the auditor do?
• What is the typical purpose of staff education after a coding and billing error?
• When appropriate, present options objectively.
• Which protocol enables self-disclosure of potential fraud under CMPs?
• What type of insurance plans may require an auditor to identify non-standard coding and reimbursement rules?
• Which statement about an IRO explaining audit results is correct?
• In the case of overpayments identified to Medicare, which statement best describes the auditor's responsibility regarding legal duties and refunds?
• Which item is part of the Corrective Action Plan?
• What should an audit report identify?
• Which audit example represents a prospective audit?
• Which statement is TRUE regarding an audit report?
• The Background section of an audit report should detail which items?
• What must the auditor clearly detail when identifying errors or code changes in the audit?
• According to professional scope, who may determine a entity's legal duty to disclose an overpayment and refund?
• What is considered the core skill of the auditor?
• The accuracy of an audit result must be validated through which process?
• What type of information can be found in the provider's contract with the insurance carrier?
• In-network provider: Which document does the auditor review to determine the provider's obligations?
• The OIG Self Disclosure Protocol (SDP) provides the ability to self-disclose potential instances of fraud involving federal healthcare programs.
• Which statement is TRUE regarding the discussion portion of the audit report?
• Which statement is TRUE regarding an IRO?
• What is an IRO?
• When speaking with Providers, avoid pointing fingers; instead focus on what they did well and outline areas where they need to improve.
• Which action best describes the recommended involvement of legal counsel during the review process to ensure understanding of conclusions?
• The recommendations can serve as a roadmap to achieve compliance.
• In what order should recommendations be presented?
• An IRO performs audits on behalf of which entity, while remaining independent?
• To whom should the audit communication be tailored?
• The IRO's report is usually submitted along with which document?
• What is the main objective of a rebuttal audit?
• Which option represents information that may be found in a contract between a provider and a commercial insurance plan that is pertinent to an auditor?
• If a provider fails to conform to an insurance company's medical policies as stated in the contract, what sanction might the payer pursue?
• Under a CIA, which issues will the IRO focus on in the annual audit?
• Where overpayments are discovered they must be disclosed and refunded.
• The statement that audits may be commissioned by an external entity is...
• Although the report is addressed to the OIG, it is usually submitted to whom?
• In an audit report, what should be included in the background component?
• How many phases does communication usually occur in, and what are they?
• In the background component of an audit report, which items should be detailed?
• If no controlling standards exist for the service, what may auditors rely on?
• If the audit scope covers multiple carriers, how should the Standard of Review section be organized?
• Which statement best describes the auditor's approach to determining error when binding rules are present?
• Which statement best describes most common commercial plans?
• Which statement best describes most common commercial plans?
• What provides an entity the ability to self-disclose potential instances of fraud involving federal healthcare programs for which liability arises under the OIG's CMP authorities?
• What should recommendations in the audit include?
• What should the audit finding report include?
• Which statement best describes the introductory section's purpose?
• Which statement regarding the scope of an IRO report is correct?
• How often are NCCI rules posted on the CMS website?
• In an audit report, which section identifies the binding standards or criteria applied during the audit?
• Why is the auditor's ability to effectively communicate audit results most critical?
• Which statement best describes the modifier reporting in NCCI audits?
• In an audit report, which section would identify the specific binding standards or criteria that were applied during the course of the audit?
• An audit on behalf of a regulatory entity is typically conducted to...
• The sample frame is the subset of all claims that possess the variable attributable to the potential error.
• If an audit is planned as either a 100 percent audit or a sample, what is the auditor expected to do?
• Who may determine a legal duty to disclose an overpayment, according to the statement?
• What is the primary purpose of the Standard of Review section in an audit report?
• The NCCI Manual is written by which organization?
• CIA is imposed for how many years?
• An SDP may be submitted in response to which statute violation?
• When there is a conflict between CMS' Internet Only Manuals (IOMs) and federal regulations, which provisions take precedence?
• Who regulates TriCare?
• Which statement best reflects the review that should occur before issuing the formal final report?
• What does SDP stand for in the context of self-disclosure to the Office of Inspector General (OIG)?
• What must an independent review organization functioning under CIA do regarding corrective action?
• What best describes the writing style of an audit report?
• The tone and language of the audit report should consider the reader's level of expertise, with an appropriate tone.
• If a sample audit uncovers a coding error that resulted in overpayments, what is the next step?
• To determine how much to focus on potential risk, understand the provider's compliance objectives.
• In the absence of a binding rule, which statement best describes the discussion of post-payment risk?
• Which statement best describes the most common type of audit?
• What does Report Attachments section include apart from references?
• CIA is typically reported to which office annually?
• Which term refers to an entity that conducts independent reviews under compliance arrangements?
• Which statement correctly describes a prospective audit?
• Which statement is TRUE regarding speaking with providers?
• Which statement regarding the recommendations section of an audit report is TRUE?
• Which term describes reporting more units than allowed by guidelines, a common coding issue mentioned in the context?
• Do not overstate potential risk and do not render legal conclusions.
• In cases of ambiguity in coding, which elements should the auditor address?
• Which action would be considered a reverse false claims provision violation under FCA?
• In the context of rebuttal audits, which statement best describes the typical outcome?
• What is a rebuttal audit?
• Who selects the IRO?
• Under reverse FCA what action avoids liability?
• After the sample is identified, the auditor determines if a 100 percent audit was feasible, or whether statistical sampling is employed.
• The Self Disclosure Protocol (SDP) addresses liability under which law?
• How long is a Corporate Integrity Agreement (CIA) usually in force?
• In the introductory section of an audit report, which details should be provided?
• If knowledge of a potential overpayment is obtained from an audit of a limited sample of claims, what does the cause of the error usually indicate?
• What is described as the most critical step in the audit process?
• Which statement best describes the IRO?
• Which section of the audit report contains the most common findings, aggregate conclusions, and key recommendations?
• When overpayments are discovered, what is the required action?
• What does a retrospective audit evaluate?
• In a prospective audit, what does binding carrier standards refer to?
• To diminish such risk, what is often recommended?
• Federal statutory requirements for TRICARE are interpreted by which department?
• Which item is a component of an audit report?
• Of the examples below, which may require an auditor to identify non-standard coding and reimbursement rules?
• What type of information can be found in the provider's contract with the insurance carrier?
• In audits associated with voluntary repayment or disclosure under SDP for potentially fraudulent conduct, who develops the corrective action plan?
• What best describes a rebuttal audit?
• If there is no binding rule, what should the discussion identify?
• Who is the auditee in an audit?
• When there is a conflict between the IOMs and federal regulations, which provisions take precedence?
• True or False. The written report is the only means by which the IRO communicates with the OIG.
• What is the likely purpose of reviewing the provider contract with the insurer?
• If the universe of potentially suspect claims is large and diverse, what is necessary?
• Post Audit Process includes which of the following activities?
• Which statement best describes the availability of insurance contracts to the auditor?
• What is the primary purpose of defining the sampling frame in the audit process?
• In-network scenario, which factor determines whether non-conformance leads to recoupment or network termination?
• What does Medically Unlikely Edits (MUE) stand for in coding practice?
• If there is a conflict between secondary guidance and binding regulation, which governs?
• Which plans are considered federally regulated insurance plans?
• Which section would typically present the references used to form opinions or conclusions?
• Which element is commonly included with an audit report?
• The writing style of an audit report should be persuasive, not purely scientific or argumentative.
• What happens to errors identified in an annual audit?
• Who is usually recommended to design the sample and perform the error rate projection?
• In the introductory section of an audit report, which elements should be detailed?
• In the incident-to-rule example, what records might be used to identify the error?
• When the sample is designed, the auditor must merely audit the sample claims.
• True or False: Sometimes the issue is widespread enough that all coding and billing staff need training.
• A good audit report should enable the reader to understand what was audited, why standards were applied, how the audit was performed, what was found, and what the auditee should do going forward.
• Most CIA's require an annual audit and will define the specific number of claims to analyze, how to sample and the issues to evaluate.
• If no controlling standard exists, which approach should be used to identify potential post-payment risk?
• If it is not feasible to audit 100 percent of potentially suspect claims, what should the auditor determine?
• In cases where an overpayment occurs without evidence of fraudulent conduct, what action should the entity take to avoid liability under the False Claims Act?
• What is the primary purpose of the NCCI manual?
• Which audit example represents a prospective audit?
• During CIA, the entity must select a neutral auditor with sufficient expertise to perform an annual audit of the entity's level of compliance.
• In what form should the audit report present the key findings?
• When discussing the auditee's options, be helpful and provide recommendations for corrective action, focusing on solutions and presenting alternatives if feasible.
• Which option is NOT a component of an audit report?
• Under the reverse false claims provision of the False Claims Act, what must be understood by an auditor?
• Which statement best describes the purpose of the Self-referral Disclosure Protocol (SDRP)?
• What type of insurance carrier might be considered a state regulated commercial insurance plan?
• According to the general rule, how should overpayments be treated?
• What information should the introductory Background section provide?
• State-regulated commercial plans frequently require identifying which type of rules?
• All potential overpayments must be investigated.
• As an independent and unbiased auditor, the IRO works on behalf of whom?
• When are Issue Oriented Findings appropriate to report?
• What is an auditor's role in the OIG Self-Disclosure Protocol (SDP)?
• In the Discussion section, what should be addressed concisely?
• Which act would be considered a False Claims Act (FCA) violation under the 'reverse false claims provision' of the FCA?
• After identifying a specific error, what is commonly done in subsequent audits?
• Which section of the audit report provides formal recommendations to address findings?
• SDRP is appropriate for detected violations under which law?
• The auditor who performs the CIA audit is known as what?
• When an audit identifies an error or non-conformance, what should the auditor do?
• What may be obligated if such an error involves improper payments from federal healthcare programs?
• When the basis for an error suggests one or more individuals contributed to the error, what is typically required?
• To accomplish this objective, the report must be organized, succinct, and well written.
• Which of the following is a possible objective of an audit?
• For federally regulated plans, which agency is responsible for interpreting statutory requirements?
• In the Standard of Review, what should be cited behind each cited standard?
• In general, is it the auditor's responsibility to develop a corrective action plan?
• In a report evaluating auditee's level of compliance, what should be delineated within each error or risk?
• What is the most important step in any compliance audit?
• Which of the following is a type of audit mentioned as an example in the material?
• Who is typically qualified to determine a legal duty to disclose an overpayment?
• Which entity issues TRICARE rules?
• Which of the following is a common component that might be included as an attachment to an audit report?
• Why should audit findings be discussed with the auditee?
• Why is expertise necessary to properly identify the relevant statutory and regulatory provisions, and any potential conflict with secondary guidance materials?
• Which statement best describes precedence when there is a conflict between guidance in secondary publications and binding regulation or statute?
• What provides an entity the ability to self-disclose potential instances of fraud involving federal healthcare programs for which liability arises under the Civil Monetary Penalty Law?
• Where were there consistent findings attributable to a specific CPT/HCPCS code, or a particular provider, would you report these findings in which format?
• Which objective aligns with identifying post-payment risk?
• If there exists a clear and unambiguous binding standard for declaring an error, what should the auditor do?
• Once an error has been identified and the provider educated, what is recommended to ensure compliance improves?
• If a provider is not contracted with the payer, which statement is true?
• What is a primary purpose of an audit report in the post-audit process?
• What is the primary purpose of the audit report?
• The audit report is the primary method of communicating the results.
• If NCCI prohibits a code pair, what is the correct billing approach?
• Which example is most likely to involve non-standard coding and reimbursement rules?
• If physician documentation is inadequate, education typically involves what?
• Issues should be presented in a logical sequence.
• A rebuttal audit primarily focuses on...
• When defending audit results, what will the competent auditor do?
• In cases where codes and modifiers could be considered erroneous by the payer, which of the following best describes the recommended action?
• What is the purpose of reviewing persuasive standards relied upon in forming audit recommendations?
• Which statement about the written audit report is true?
• Among the examples below, which may require an auditor to identify non-standard coding and reimbursement rules?
• To justify an allegation of error which statement is correct?
• Which item is not typically included in a Corrective Action Plan?
• Which scenario describes the relationship between legal counsel and the audit review process?
• What must be done before issuing the formal and final audit report?
• Which is a potential outcome under the OIG Self Disclosure Protocol?
• Which type of audit is typically performed in response to a payer audit, with the goal of validating or refunding the payer's conclusions?
• Which statement about the OIG Self Disclosure Protocol (SDP) is accurate?
• True or False: Service-specific findings should be replaced by issue-oriented findings in all cases.
• When there is a conflict between CMS' Internet Only Manuals (IOMs) and federal regulations, which provisions take precedence?
• Under CIA, what is the independence obligation of an independent review organization?
• The recommendations in an audit report can serve as a roadmap to achieve compliance.
• What is the auditor's purpose regarding post-payment risk in a CIA?
• Medicare program rules are governed by which agency?
• The IRO's report is typically submitted to which recipients along with the annual report?
• What is described in the Summary of Audit Findings?
• When the audit reveals an error or non-conformance, what must be identified and cited?
• Which statement is TRUE regarding NCCI?
• If the OIG identifies an issue and imposes a CIA, what will be the focus of the IRO in its annual audit?
• Which of the following best describes an Independent Review Organization (IRO)?
• Which is the best practice when discussing audit findings with the provider?
• In what scenario might no auditing be required because the overpayment amount can be determined by simple data analysis?
• Imposing non-binding standards may expose the entity to higher overpayments.
• Why should audit findings be discussed with the provider audited?
• Which section of the audit report contains concise summaries of findings?
• If a prior audit found a problem for a specific provider and code, how would the audit scope typically be described?
• What are auto and workers' compensation plans considered to be?
• What is the first step in developing a corrective action plan after an audit results?
• Refunds of identified overpayments are meant to avoid liability under which law?
• When a provider is not contracted with the payer, which statement is true?
• Why is a coding audit unlikely to identify Stark or AKS violations?
• After identifying the binding standards, what is the auditor's evaluation focus?