CPMA Test Questions with Right Solutions

Medically Unlikely Edits - Define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT code Purpose of the medically unlikely edits - To help reduce the paid claims error rate for Medicare Part B claims Medicare Modernization Act - Required a 3-year Recovery Audit demonstration, which ran between 2005 and 2008; during the demonstration, Medicare employed Recovery Auditors to identify overpayments and underpayments made to healthcare providers and suppliers in randomly selected states Tax Relief and Healthcare Act of 2006 - Requires a permanent and nationwide Recovery Audit program by 2010 How many Recovery Audit Contractors does Medicare currently have? - 4, divided by region Recovery Audit Contractors (RACs) - Review claims on a post-payment basis and use the same CMS regulations that providers are required to follow Fee-For-Service (FFS) Recovery Auditors - Contract with CMS to identify Medicare FFS improper payments; if an improper payment is identified, a review results letter is sent to the provider that includes the decision and rationale for that decision How long can FFS Recovery Auditors go back and request claims after the date the claim is paid? - 3 years 3 types of review performed by FFS Recovery Auditors - Automated, semi-automated, and complex Automated review - no medical record needed; improper payments are determined based solely on the submitted claims and regulatory guidelines such as National Coverage Determinations, Local Coverage Determinations, and the CMS Manuals Semi-automated review - claims review using data and potential human review of a medical record or other documentation; medical records supplied at the discretion of the provider to support a claim identified by data analysis as an improper payment Complex review - medical record required