Medicare Ethics and Compliance Practice Test

These questions are part of the practice quiz. Start practicing

• Which piece of information is essential in a thorough needs assessment to determine formulary status?
• Which guideline should you follow before recommending a plan change?
• What is the purpose of a corrective action plan (CAP) in responding to findings?
• Which statement is accurate when a consumer has a Power of Attorney (POA) regarding enrollment forms?
• What is the purpose of periodic audits in Medicare compliance?
• Which of the following is NOT a key element of the FCA?
• If an AKS arrangement fails to meet safe harbor criteria, what is the likely status?
• If the consumer indicates that someone assists them with decisions such as enrolling in health insurance coverage, what should you do?
• Which of the following are examples of phrases that must not be spoken by an agent when a consumer is contemplating a plan change?
• What is the role of CMS regional offices in Medicare compliance investigations?
• What is a potential negative outcome when a consumer misunderstands information?
• In the context of comparing plans, what is the primary factor used to assess access to preferred healthcare providers?
• What is upcoding and why is it a risk?
• What is an example of a Stark Law exception for physician-owned entities?
• Which of the following are examples of lead generation materials that might result in an inbound call from a Medicare-eligible consumer?
• How does Stark Law differ from AKS in key areas?
• Which element helps evaluate how the new plan may affect drug coverage and costs for the consumer's medications?
• When discussing plan details, what must be explained regarding out-of-network providers?
• What misstep did Dino commit when discussing Medicare Advantage plans for the new plan year?
• How should an organization respond to a noncompliance finding?
• Which statement about plan features is not guaranteed and should be verified during enrollment?
• What document is obtained no less than 48 hours prior to the start of the appointment to identify the discussable products?
• How can marketing practices potentially harm beneficiaries and trigger penalties?
• Which option will provide prescription drug coverage for a consumer who is currently enrolled in a MA-Only plan?
• What penalties can arise from fraud or false claims leading to exclusion?
• Why must a physician-owned entity provide designated health services only under permissible conditions?
• Which item is NOT a component of a thorough needs assessment?
• Select the element you must compare when a consumer is considering changing plans.
• Which statement about a stand-alone Prescription Drug Plan (PDP) is true?
• When should you proceed with an enrollment?
• Why must conflicts of interest be disclosed under Stark and AKS?
• Which statement regarding Star Ratings is true?
• What does the LEIE list, and how is it used by providers?
• Which statement best captures the relationship between risk assessment and internal audits in a Medicare compliance program?
• What is a potential outcome if a member misperceives that the new plan has the same or more features than current plan?
• What is the purpose of a formal risk assessment in compliance?
• Which statement about election periods is true?
• Which statement describes how to describe a plan's benefits to avoid misinformation?
• When you discover a consumer is already enrolled in a Medicare Advantage plan, what must you do prior to making a plan recommendation and enrolling the consumer in a new plan?
• Beyond looking up the consumer's current providers and medications, what else should you learn about the consumer when conducting a thorough needs assessment?
• A thorough needs assessment will include which of the following components?
• The "Statement of Understanding" ensures that during telephonic enrollment the consumer understands what they are enrolling in. Which option best describes this document?
• To complete an Enrollment Application on behalf of a consumer, what authority must the individual have?
• What beneficiary rights relate to privacy, access, and complaints?
• Which element most directly informs access to the providers the consumer wants?
• Why is staff training critical to a Medicare compliance program?
• What is the purpose of LEIE in hiring or contracting decisions?
• Which statement is not guaranteed when advising a consumer about switching plans?
• Which statement best supports clear communication during plan changes?
• What is a likely consequence of failing to comply with enrollment and credentialing requirements?
• How should organizations distinguish compliant beneficiary outreach from improper marketing?
• What is LEIE and who maintains it?
• In AKS, what is the role of safe harbors?
• If a consumer appears confused, what is an appropriate action for the agent?
• What is a Corrective Action Plan (CAP) and when is it used?
• Which statement accurately reflects beneficiary privacy rights?
• Which statement is true for Aries' mid-year switch from a PDP to a Medicare Advantage plan with a November 1 effective date?
• What is a 'safe harbor' in the AKS and why is it important?
• Which of the following is an essential factor to compare when a consumer considers changing plans?
• Which statement about the LEIE's purpose is correct?
• What is the purpose of a needs assessment?
• Which statement is true about Special Election Periods triggered by qualifying life events?
• When must the Scope of Appointment be obtained from the consumer for an in-person or telephonic sales presentation (unless an exception applies)?
• What is a typical consequence of misrepresentation in enrollment and credentialing?
• When discussing benefits with the consumer before enrollment, which statement must be disclosed?
• What information must you provide to the consumer at minimum during your call greeting?
• Which describes Permission to Contact (PTC) guidelines?
• In corrective action plans, what is essential for accountability?
• Which action demonstrates compliant interaction with a consumer about plan options?
• Why must Medicare claims document medical necessity?
• When a consumer asks about a plan during a call, you should:
• Which is NOT a feature of a Corrective Action Plan (CAP)?
• What considerations govern the distribution of physician or staff gifts and incentives in a compliant program?
• In Gene's February call, which option describes what he can do?
• Which statement is correct about a like-plan change?
• When are you required to conduct a thorough needs assessment?
• What is a Business Associate Agreement (BAA) and its role in HIPAA?
• Which statement best describes choosing the plan that fits the member's needs?
• If someone assists a consumer with decision-making, what is the compliant action?
• Which statement must be understood regarding drug coverage before enrolling?
• What happens on the plan effective date when a member enrolled in a Medicare Supplement and stand-alone PDP enrolls in a Medicare Advantage plan that includes drug coverage?
• Which of the following qualifies as a designated health service (DHS) under Stark law?
• Which statement is true about power of attorney in enrollment processing?
• What might happen if you rely on a benefit or plan feature a consumer mentions they saw or heard in an ad?
• When advising a consumer who is considering changing Medicare plans, which element is essential to compare to understand access differences?
• Which statement best describes the Office of Inspector General's (OIG) role in Medicare compliance?
• Prior to making a plan recommendation, what is required?
• If a consumer seems confused during a discussion of a Prescription Drug plan, what is an appropriate step for the agent?
• Which of the following is NOT a guideline you should follow to help consumers understand the information you present?
• What risks are associated with enrollment and credentialing misrepresentations?
• Which of the following should be verified to avoid drug coverage surprises after enrolling in a new plan?
• What is meant by documentation integrity in the billing process?
• Which guideline helps ensure consumer understanding during a phone sale?
• A consumer asks about a plan benefit seen in an ad and mentions a money-back feature from Social Security. Which approach best guides the interaction?
• Which statement best reflects compliant handling when a consumer mentions a benefit from an ad during a call?
• Qui tam actions, as mentioned in whistleblower protections, are actions brought under which law?
• A consumer turns 65 soon and calls; On the day of the call, what can Gene do?
• Rosanna is enrolled in an MA-Only Private Fee-for-Service plan and wants prescription drug coverage. Which option is available to her if she is in a valid election period?
• What is required before a marketing appointment taking place in person, online, or by phone?
• In which situation may the Medicare Advantage organization disenroll a member from an MA plan?
• Cynthia is turning 65 on July 5. Her Medicare Part A and Part B will be effective on July 1. Using her Initial Election Period (IEP), when can she submit an application for a Medicare Advantage or Prescription Drug plan?
• How should internal investigations be conducted to preserve evidence?
• Dino explained a plan to a consumer on September 29 but could not accept an enrollment application until October 15. What did Dino do that was NOT compliant?
• What protections exist for whistleblowers reporting Medicare fraud?
• Which item is NOT a component of a thorough needs assessment?
• What document must be used to authorize someone to enroll if the consumer cannot attend?
• Why is coordination of benefits important in Medicare billing?
• Which scenario could trigger FCA/AKS exposure?
• Which statement best differentiates false claims from false statements in Medicare enforcement?
• When a consumer asks why an MA Plan has a 2-star rating, the agent should tell the consumer that the plan has received a
• Before enrolling, which understanding about drug coverage should you ensure the consumer has?
• Define the False Claims Act (FCA) and its relevance to Medicare.
• Aries is considering enrolling in a Medicare Advantage plan with prescription drug coverage after leaving a stand-alone PDP. Which option is available to Aries?
• Which action is permissible during the Annual Election Period?
• Which statement about enrolling in a new plan is not guaranteed?
• What are the consequences of inadequate documentation in the billing process?
• Which document identifies the scope of products that can be discussed at a personal marketing appointment?
• To avoid confusing or misleading a consumer, what type of information must the agent provide when presenting a plan?
• Civil penalties differ from criminal penalties in Medicare enforcement how?
• Stark Law is primarily concerned with which aspect of physician relationships?
• When must an MA Plan or stand-alone PDP disenroll a member?
• Which statement is true about election periods?
• Which statement best describes effective training to ensure compliance?
• What is unbundling and why is it noncompliant?
• Why should a person who assists the consumer with decisions be present on the enrollment call?
• What describes Scope of Appointment?
• What constitutes a HIPAA breach and typical notification requirements?
• Which element is essential to compare to understand the costs and coverage of the new plan relative to the current plan?
• Which statement is true when selling Medicare plans over the telephone?
• Which item is NOT considered a core component of a Medicare compliance program?
• How are whistleblower protections related to retaliation against whistleblowers?
• Which role is essential in a Medicare compliance program?
• When should you mail or provide the Enrollment Guide for the plan recommended to the consumer?
• During a telephone conversation, if a consumer mentions a specific plan benefit from an advertisement, what is the best step?
• What is the purpose of a confidential reporting mechanism in a Medicare compliance program?
• What does the Anti-Kickback Statute prohibit in Medicare transactions?
• Which statement about LEIE is true?
• Which description should you not use when comparing the benefits of a new plan to the consumer's current plan?
• What is self-referral, when is it allowed, and what safeguards apply under Stark law?
• Which action is part of best practice before recommending a new Medicare Advantage plan to a consumer?
• How does Stark Law address physician referrals to designated health services?
• What is the primary purpose of Medicare ethics and compliance programs?
• What best describes documentation integrity in relation to coding and billing?
• Which factor should be reviewed to assess potential changes in medication coverage under a new plan?
• As an agent, you have an obligation to enroll a consumer in a product that is:**
• Which statement about enrolling in a new plan is not guaranteed?
• In which situation is a Medicare Advantage member involuntarily disenrolled from their MA plan?
• Which factor is a primary consideration when comparing plans for access to care?
• Which entity maintains the LEIE?
• Which activity supports ongoing Medicare compliance program?
• Which statement correctly reflects expectations about plan change?
• If a member assumes their new plan has everything their old plan had and more, what is a likely outcome?
• Which statement describes a 'like' plan change?
• How is medical necessity shown in documentation?
• What should you verify about drug coverage when proposing a new plan?
• Whose email address may the agent enter into the LEAN enrollment application?
• In what product should agents enroll consumers?
• Which statement describes falsification of medical records in the Medicare context?
• Whose email address may the agent enter into the applicant information section of LEAN enrollment application?
• Which document is used to confirm the details of a telephonic enrollment and its disclosures after the call?
• During the Annual Election Period, which actions are allowed for Medicare plans?
• What might happen when a member assumes that their new plan has everything their old plan had and more?
• Which document ensures that verbal enrollment acknowledgment includes plan and disclosures?
• What is a primary benefit of independent audits in Medicare compliance programs?
• Which description should you not use when comparing benefits of a new plan to the consumer's current plan?
• Which of the following is NOT a function of the Office of Inspector General (OIG) in Medicare compliance?
• What information must you provide to the consumer at minimum when you conduct your call greeting?
• Which of the following is true about confidential reporting channels and hotlines in Medicare fraud reporting?
• Why are internal audits and ongoing monitoring essential in Medicare compliance?
• Which of the following are examples of what an agent must review with a consumer prior to completing an enrollment application?
• What action best describes the follow-up after corrective actions are implemented?
• What should you do if a consumer asks you to enroll in a plan that they saw advertised as having a money-back feature?
• How can a facility maintain ongoing compliance amidst evolving Medicare requirements?
• What is a potential risk if you fail to conduct a thorough needs assessment?
• What should the consumer understand before they agree to proceed with enrolling in a new plan?
• During a needs assessment, which information should be collected about the consumer's current providers and medications?
• Which information helps determine whether a plan is in-network for a consumer?
• Which document must be obtained no less than 48 hours before an in-person, online, or telephonic marketing appointment?
• The MA Open Enrollment Period can be used by a consumer who is not currently enrolled in an MA Plan.
• How does a safe harbor under AKS affect permissible arrangements?
• Which statement is true regarding the interaction between Medicare Advantage plans and prescription drug coverage?
• What is the purpose of the Statement of Understanding?
• What criterion should guide the agent’s recommendation of a Medicare product?
• What is the "minimum necessary" standard under HIPAA?
• How should you confirm understanding of tradeoffs?
• How should conflicts of interest be managed in relationships with vendors and referrals?
• Why is an agent prohibited from entering their own email address in LEAN?
• Which statement describes a robust Medicare compliance program culture?
• Which of the following is not considered unsolicited contact with a Medicare eligible consumer according to CMS regulations and UnitedHealthcare's rules?
• Which plan should the consumer enroll in?
• When comparing an alternative Medicare Advantage plan, which of the following must you not use to describe benefits of the new plan?
• What is the earliest date in October when a new plan year can be presented to consumers?
• Which date is the earliest date an enrollment application could be accepted in the scenario described?
• Which of the following is an example of a Stark Law exception used by physician-owned practices?
• Which statement about discussing benefits before enrollment is true?