AAPC-CIC Certified Inpatient Coder - Set 5 - Part 2

Correct Answer: Separately for each party involved

OIG guidance states that liability under the Federal anti-kickback statute is determined separately for each party involved. Each person who offers, pays, solicits, or receives remuneration is assessed on its own conduct and intent. Option a is incorrect because treating the arrangement as a single shared unit contradicts the rule that each party's liability stands on its own. Option b is incorrect because liability is not placed on the recipient alone; OIG guidance states it is assessed for every party involved, including the one offering remuneration. Option c is incorrect because the statute reaches anyone who offers, pays, solicits, or receives remuneration, so the referral source is not the sole party exposed.

Correct Answer: Mandatory exclusion from Federal health care programs

OIG guidance states that a violation of the Federal anti-kickback statute is a felony, and conviction also leads to mandatory exclusion from Federal health care programs, including Medicare and Medicaid. Option b is incorrect because the guidance says liability is determined separately for each party involved, so no equal sharing between parties is presumed. Option c is incorrect because a violation is described as a felony, while a misdemeanor appears in the statute only for repeated violation of assignment terms, which is a different offense. Option d is incorrect because the guidance states that conviction leads to mandatory exclusion, and administrative exclusion proceedings are a separate OIG action, not a payer's discretionary choice.

Correct Answer: Ending review after the self-referral law assessment

The physician self-referral law and the Federal anti-kickback statute are two different laws requiring separate evaluations. An arrangement permissible under the physician self-referral law still needs analysis for anti-kickback compliance, so stopping early is wrong. Option a is incorrect because arrangements that may implicate the physician self-referral law, the anti-kickback statute, or both are exactly the ones the guidance says should be analyzed once identified. Option b is incorrect because starting there is the usual best practice, since the physician self-referral law is a strict liability statute, so this step does not conflict with guidance. Option d is incorrect because the guidance stresses tracking and closely reviewing financial relationships with referring physicians, and it does not object to a compliance role performing the assessment.

Correct Answer: Designated health services

The physician self-referral law is implicated only when six elements are present: a physician, a referral, designated health services, payable by Medicare, an entity, and a financial relationship with that entity. Option a is incorrect because that is a sanction for violations, which follows a violation and cannot serve as a condition for a prohibited referral. Option b is incorrect because exceptions operate afterward; a referral is prohibited when the six elements exist unless an exception applies and its requirements are satisfied. Option c is incorrect because the physician self-referral law is a strict-liability statute, so no showing of intent is required and intent is not one of the six elements.

Correct Answer: The corporation that presented the claim

An entity furnishes DHS if it performed services billed as DHS or presented a claim to Medicare for them. The corporation submitted the claim, so it is the entity under the Stark definition. Option a is incorrect because individual technicians are employees, and the definition looks to the person or organization that performed the billed services or presented the claim, which here is their employer. Option c is incorrect because the definition of entity excludes the referring physician himself or herself, though it does include his or her medical practice. Option d is incorrect because a beneficiary is the recipient of care and neither performs services billed as DHS nor presents a claim to Medicare.

Correct Answer: Within 90 consecutive calendar days of termination

The special rule for reconciling compensation requires the entity and the physician to reconcile all discrepancies no later than 90 consecutive calendar days after the arrangement expires or terminates, so the entire remuneration is paid as the terms require. Option b is incorrect because the special rule gives the parties a longer window than 30 days, so a deadline this short misstates the regulation's timeframe. Option c is incorrect because the regulation sets a longer reconciliation period after expiration or termination, so 60 days understates what the rule allows the parties. Option d is incorrect because the rule does not allow that much time; stretching the window to 180 days would go beyond the limit the regulation states.

Correct Answer: Fair market value

Fair market value for equipment rental is the value in an arm's-length transaction of rental property for general commercial purposes, not taking into account its intended use, and consistent with the general market value of the transaction. Option a is incorrect because the individual unit of time is a way to measure how compensation is paid when it is not per item or per service, not a valuation standard. Option b is incorrect because it concerns who holds the right to payment for DHS, such as an employer or a contractual arrangement, and not how rental property is valued. Option d is incorrect because it applies when a physician's practice bills for the technical or professional component of a diagnostic test, so it does not set a rental value.

Correct Answer: It can qualify, since the interest may be through debt

Under 42 CFR 411.354(b), an ownership or investment interest may be through equity, debt, or other means, and it includes an interest in an entity that holds an interest in an entity furnishing DHS. Option a is incorrect because the definition expressly includes an interest in an entity that holds an ownership or investment interest in any entity furnishing DHS. Option b is incorrect because the regulation says an interest may be through equity, debt, or other means, so equity is not the sole form. Option c is incorrect because loans, bonds, and other financial instruments are listed as ownership or investment interests, while a compensation arrangement is a separate category involving remuneration.

Correct Answer: Ownership or investment interest, or compensation arrangement

The Stark definition in 42 CFR 411.354 says a financial relationship is a direct or indirect ownership or investment interest in an entity furnishing DHS, or a direct or indirect compensation arrangement. Option a is incorrect because the regulation names no referral agreement as a form of financial relationship; it pairs ownership or investment interest with compensation arrangement instead. Option c is incorrect because half of this pair is right, but a lease agreement is not a separate form in the definition; the other form is ownership or investment interest. Option d is incorrect because the definition lists no service contract as its own category, and investment interest appears there together with ownership, not as a standalone form paired with contracts.

Correct Answer: Profits from all the group's designated health services

When fewer than five physicians are in the group, overall profits means the profits derived from all the designated health services of the group. The five-physician component option is available only to larger groups. Option a is incorrect because a component of five or more physicians applies to larger groups; a group below that size has no such component to use. Option b is incorrect because referral-based profits would tie pay directly to the volume or value of referrals, which the group practice rules prohibit apart from the special profit share rules. Option c is incorrect because the definition rests on profits from designated health services, while location and specialty-based practices are what the rules address for revenue from services that are not DHS.

Correct Answer: Knowingly presenting a false or fraudulent claim

The statute imposes liability on any person who knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval. Knowledge of the falsity is part of the act. Option b is incorrect because timely repayment is the step an entity takes to avoid False Claims Act liability, so it cannot be a liability-creating act. Option c is incorrect because pursuing cases before an HHS administrative law judge describes how OIG handles civil monetary penalty cases, not an act that creates False Claims Act liability. Option d is incorrect because regular internal audits are a proactive compliance measure recommended by OIG guidance, which supports compliance rather than creating liability.

Correct Answer: Repay the overpayment to the Government

OIG guidance states that even an innocent billing mistake leaves the entity obligated to repay the money to the Government. Repaying identified overpayments to Medicare and Medicaid is how an entity avoids False Claims Act liability. Option a is incorrect because the guidance requires the entity to act on its own after identifying the overpayment; it does not make repayment depend on an OIG investigation starting. Option c is incorrect because that protocol covers actual or potential violations of the physician self-referral law (PSL), which is a different law and not the issue in a simple billing error. Option d is incorrect because an innocent billing mistake does not remove the duty to repay, so lack of intent does not permit keeping the money.

Correct Answer: An overpayment

Under OIG exclusion authority, no Federal health care program payment may be made for items or services furnished by an excluded person. Payment for such claims results in an overpayment, even without a provider identification number. Option a is incorrect because permissive exclusion is a discretionary OIG authority based on listed grounds, and it does not name the status of a payment already made. Option b is incorrect because mandatory exclusion is an OIG action following certain criminal convictions; it describes how a person becomes excluded, not what paid claims become. Option c is incorrect because an exclusion bars Federal health care program payment for items or services furnished by an excluded person, so these payments are not allowed.

Correct Answer: Beneficiary Inducements CMP

The Beneficiary Inducements CMP applies to any person who offers or transfers remuneration to a Medicare or State health care program beneficiary that the person knows or should know is likely to influence the beneficiary's selection of a particular provider. Option a is incorrect because it lets OIG exclude a person whose health care license was suspended, revoked, or surrendered for reasons of competence, performance, or integrity. Option b is incorrect because it addresses failure to provide an adequate medical screening examination to emergency department patients, not remuneration offered to influence a beneficiary's choice of provider. Option d is incorrect because it obliges an entity to report and repay identified overpayments within a set period, which has nothing to do with offering remuneration to beneficiaries.

Correct Answer: Code of conduct

OIG guidance describes the code of conduct as an important tool to communicate an organization's mission, goals, and ethical requirements. It also articulates the commitment to comply with Federal and State laws and regulations. Option b is incorrect because a handbook only delineates or expands upon the code and needs regular updating as requirements change; the code itself carries the mission and ethics message. Option c is incorrect because these serve as a roadmap for duties, workflow, documentation, and oversight roles, rather than conveying the mission, goals, and ethical requirements of the organization. Option d is incorrect because this report covers program implementation, operation, needs, and compliance risks; it is a leadership oversight communication and not a statement of organizational mission.

Correct Answer: Ensuring the compliance officer has direct, uninhibited access to the board

OIG guidance says the board should ensure the compliance officer has direct and uninhibited access to the board at any time, regardless of reporting structure, so risks can be reported without fear of repercussions. Option a is incorrect because committee charter revisions are an adjustment the compliance officer may recommend to improve committee performance, not a safeguard for the officer's reporting. Option b is incorrect because an intranet site supports access to the code, policies, and procedures under policy maintenance and does nothing to protect the officer's reporting. Option d is incorrect because organizational duties of that kind could impede the compliance officer's ability to evaluate and report on risk, so they would weaken independence.

Correct Answer: It may deter individuals from coming forward

OIG guidance says the entity should not deter individuals from coming forward, for example by requiring personnel to bring concerns to a manager or supervisor before contacting the compliance officer. Independent paths keep reports from being diverted. Option a is incorrect because logging is a duty of the compliance officer or designee after receipt, so a supervisor-first rule does not itself breach the logging requirement. Option c is incorrect because training waivers concern contractors whose own compliance training satisfies certain requirements, and they have no connection to the order in which concerns are reported. Option d is incorrect because performance review recognition is an incentive for substantiated concerns, and it is not affected by requiring a report to go to a supervisor first.

Correct Answer: Record it in the disclosure log

OIG guidance states that all disclosures of compliance concerns should be recorded in a log maintained by the compliance officer or designee, regardless of how they are made, including reports made to another entity leader. Option a is incorrect because recording is expected promptly following receipt by the compliance officer or designee, not delayed until a violation is confirmed by counsel. Option b is incorrect because independent reporting paths exist so that reports cannot be diverted by supervisors or other personnel, which makes sending it back contrary to the guidance. Option c is incorrect because guidance says all disclosures should be logged regardless of how they are made, so a report to a leader still counts.

Correct Answer: I and II

OIG guidance says the effectiveness review should assess how effective each element of the compliance program is, and the board should direct the entity to perform it. Statements I and II are accurate. Option b is incorrect because the OIG toolkit is not a checklist, and using all of its tools or many of them is described as impractical and not recommended. Option c is incorrect because reviewers are directed to report their findings and recommendations directly to the board, not to a coder, so statement IV fails. Option d is incorrect because both statements contradict the guidance: the toolkit should not be applied in full, and review results go directly to the board.

Correct Answer: Risks identified by the annual risk assessment

OIG guidance says the Compliance Committee should include in the compliance work plan a schedule of audits based on risks identified by the annual risk assessment, with capacity to add audits for risks found during the year. Option a is incorrect because payer record requests are not named as the basis for the work plan's audit schedule, which the guidance links to the entity's own risk assessment. Option c is incorrect because the guidance points to risks from the annual assessment and adds capacity for risks found during the year, so a backward-looking list alone falls short. Option d is incorrect because OIG guidance ties the audit schedule to assessed risk, not to staffing convenience; auditor expertise matters for who performs audits, not what is scheduled.