CPMA Analysis and Communications Practice Test

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