CPMA Analysis and Communications Practice Test

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