AAPC-CIC Certified Inpatient Coder - Set 5 - Part 3

Correct Answer: Federal fraud and abuse enforcement agencies

OIG guidance lists technology companies, new investors, and organizations providing non-traditional services as new entrants. Federal agencies that regulate health care and enforce fraud and abuse laws are the regulators new entrants must learn about, not entrants themselves. Option b is incorrect because the guidance names technology companies, both established and start-up, among the growing number of new entrants to the industry. Option c is incorrect because new investors appear in the guidance's list of new entrants, so they belong to the set the question describes. Option d is incorrect because organizations offering non-traditional services in health care settings, with care coordination as an example, are described as new entrants.

Correct Answer: Overpayments and False Claims Act liability

OIG guidance states that quality and patient safety concerns, such as excessive services and medically unnecessary services, can lead to overpayments and may cause False Claims Act liability, in addition to patient harm. Option a is incorrect because a compliance contact is a designation for small entities without a compliance officer, and the guidance does not link quality concerns to losing that role. Option b is incorrect because the guidance says entities should incorporate quality and patient safety oversight, and it describes no automatic removal of board involvement as a result of these concerns. Option d is incorrect because an arrangements tracking system addresses financial arrangements and fraud and abuse laws; the guidance does not tie excessive or unnecessary services to replacing it.

Correct Answer: Financial incentive to improperly upcode claims

OIG guidance on the claim development and submission process says policies should provide that compensation for billing department coders and billing consultants should not provide any financial incentive to improperly upcode claims. Option a is incorrect because the guidance actually wants this documentation available to coding staff so that accurate code assignment is possible, so it is not something to avoid. Option b is incorrect because time spent is a documentation element recorded for the activity leading to the record entry, not a compensation rule for coders or consultants. Option c is incorrect because gainsharing concerns physician compensation tied to reduced or limited patient services, which OIG discusses separately from how billing department coders and consultants are paid.

Correct Answer: Primary care physician recruited to a health professional shortage area

The recruitment safe harbor is very limited. It protects certain arrangements that hospitals use to attract primary care physicians and practitioners to health professional shortage areas, as defined in regulations. Option a is incorrect because the safe harbor expressly excludes recruitment of specialists, so a shortage-area location does not bring this arrangement within its protection. Option c is incorrect because protection depends on the area being designated as a health professional shortage area, and recruitment in areas without that designation is not protected. Option d is incorrect because joint recruitment with existing physician practices in the area is one of the arrangements the safe harbor does not cover.

Correct Answer: mismanagement

OIG guidance states that the OIG Hotline accepts tips and complaints about potential fraud, waste, abuse, and mismanagement in HHS programs. Mismanagement is the fourth category named alongside the other three. Option b is incorrect because self-disclosure is a separate OIG process for entities to report their own potential violations, not a category of problem the Hotline receives tips about. Option c is incorrect because overpayment is a payment concept that OIG guidance does not list alongside fraud, waste, and abuse in describing what the Hotline accepts. Option d is incorrect because exclusion is an enforcement sanction affecting participation in Federal health care programs, covered by a Special Advisory Bulletin, and is not named among the Hotline's reportable concerns.

Correct Answer: Recovery Audit Contractor Reports

OIG guidance lists the Work Plan, Top Management Challenges, Semiannual Reports to Congress, Health Care Fraud and Abuse Control Program Reports, Office of Audit Services Reports, and Office of Evaluation and Inspection Reports. Recovery Audit Contractor Reports are not named. Option a is incorrect because these reports appear in the same list of OIG materials that support risk assessments, compliance priorities, and targeted audits. Option c is incorrect because the OIG Work Plan is named in OIG guidance as a key publication describing audits and evaluations that are underway or planned. Option d is incorrect because OIG guidance includes these reports among the publications consulted for general risk trends and subsector-specific risks.

Correct Answer: Prepayment medical review

Prepayment medical review is a review that occurs before an initial determination for payment is made on the selected claim, to determine whether payment should be made. It happens prior to Medicare payment. Option a is incorrect because it is the first level of appeal, an independent review of an initial determination that has already been made. Option b is incorrect because it occurs after payment has been made on the selected claim, to decide whether the initial payment determination was appropriate. Option c is incorrect because it relies on claims data analysis to identify improper payments and takes place after the claim was already paid.

Correct Answer: Compliance Leadership and Oversight

OIG guidance lists the seven elements in order, beginning with Written Policies and Procedures. Compliance Leadership and Oversight follows as Element 2, ahead of Training and Education and the remaining elements. Option a is incorrect because it is numbered sixth in the OIG list, ahead of only the final element on responding to detected offenses. Option b is incorrect because it sits fifth in the OIG list, following the elements on training and on lines of communication with the compliance officer. Option d is incorrect because OIG guidance lists it third, after Written Policies and Procedures and Compliance Leadership and Oversight, so it is not the second element.

Correct Answer: National coverage determination

Under 42 CFR 405.968(b), national coverage determinations, CMS Rulings, designated Council decisions, and applicable laws and regulations are binding on the QIC. LCDs and CMS program guidance receive substantial deference but are not binding. Option a is incorrect because manual instructions are CMS program guidance too, so a QIC is free to depart from them when it finds a sound reason. Option c is incorrect because the regulation says QICs are not bound by LCDs, though they give substantial deference to them when applicable to the case. Option d is incorrect because program memoranda count as CMS program guidance, which a QIC weighs with substantial deference but may decline to follow.

Correct Answer: It is inconsistent because screening cannot be delayed for payment inquiries

OIG guidance on EMTALA states that a required medical screening or treatment of an emergency medical condition cannot be delayed to inquire about an individual's method of payment or insurance status, so the policy conflicts with it. Option a is incorrect because receiving-facility space is a transfer requirement, and this policy describes arrival and screening at the ED, with no transfer involved. Option b is incorrect because that certification concerns transferring an individual with an unstable emergency medical condition, not delaying a screening exam to ask about coverage. Option c is incorrect because diversion status does not excuse the hospital; the guidance requires services for an individual who comes to the ED even when the ED is on diversion.