AAPC-CPCO Certified Professional Compliance Officer - Set 2 - Part 1

Correct Answer: Same standard of proof as the False Claims Act

The Civil Monetary Penalties Law is an administrative remedy, similar in scope and effect to the False Claims Act, with exactly the same standard of proof. Negligent mistakes are not covered, so only return of the funds follows. Option a is incorrect because the Civil Monetary Penalties Law is said to carry exactly the False Claims Act standard, which covers actual knowledge, reckless disregard or deliberate ignorance. Option b is incorrect because OIG guidance says physicians face no administrative penalties for innocent errors or even negligence, so the remedy does not reach negligent mistakes. Option c is incorrect because that burden belongs to criminal penalties, where intent to defraud must be proved; the administrative remedy is described as similar in scope to the False Claims Act.

Correct Answer: It is a resource, not a model compliance program

OIG states that its compliance program guidance does not constitute a model compliance program. It is a voluntary resource that is not one-size-fits-all or all-inclusive, so copying it as a complete program rests on a mistaken assumption. Option a is incorrect because OIG states the documents are not completely comprehensive or all-inclusive of compliance considerations and risks for every organization, so full coverage cannot be assumed. Option c is incorrect because OIG uses "should" to present voluntary, nonbinding guidance, and the guidance is not binding on any individual or entity. Option d is incorrect because OIG says the guidance is not intended to be one-size-fits-all; subsector-specific risk areas are the purpose of the forthcoming ICPGs instead.

Correct Answer: Whether a referral source pays fair market value for compliance services

Step One evaluates whether standards are current, whether individuals carry out responsibilities, and whether claims are submitted appropriately. Fair market value payment is a collaboration safeguard against anti-kickback and self-referral problems, not part of the evaluation. Option b is incorrect because OIG guidance counts staff performance of assigned duties as part of the evaluation, since it tests whether the compliance program is actually working. Option c is incorrect because the OIG names this as the first part of the ongoing evaluation, which checks that the practice's own standards and procedures remain current and accurate. Option d is incorrect because claim submission is listed directly in the evaluation, and audits are described as the way to find the problem areas behind faulty claims.

Correct Answer: Training and education

OIG recommends that physicians consider limiting participation in a sponsoring provider's compliance program to training and education or policies and procedures, which helps prevent possible anti-kickback or self-referral issues. Option a is incorrect because providing compliance oversight without charging fair market value is cited as a situation implicating the anti-kickback and Stark self-referral laws, so it is not a recommended area. Option b is incorrect because OIG guidance names claims review by a sponsoring entity, without fair market value payment, as an example that would implicate the anti-kickback and Stark laws. Option c is incorrect because the referral source must not be perceived as, nor actually be, running the practice compliance program at no charge, which is the conflict to avoid.

Correct Answer: Reducing the prospect of erroneous claims and fraudulent activity

OIG guidance states that written standards and procedures help reduce the prospect of erroneous claims and fraudulent activity by identifying risk areas and establishing tighter internal controls, while also helping to identify aberrant billing practices. Option a is incorrect because the guidance places standards and procedures after the internal audit, which identifies the risk areas that the standards then address, so audits remain necessary. Option b is incorrect because audit results may point to topics for the training and educational system, so written standards work alongside training rather than substituting for it. Option d is incorrect because the guidance describes reducing erroneous claims and fraud through tighter internal controls, not any assurance about how a payer will adjudicate claims.

Correct Answer: Claims for services that are not reasonable and necessary

OIG guidance lists claims for equipment, supplies and services that are not reasonable and necessary as a coding and billing risk area. It means seeking reimbursement for a service not warranted by the patient's documented medical condition. Option a is incorrect because OIG guidance lists it as its own bullet, separate from the risk area tied to whether the documented condition warrants the service. Option c is incorrect because it covers services never performed, such as laser surgery billed by a provider who lacked the equipment, rather than services lacking support in the documented condition. Option d is incorrect because it means billing the same item or service more than once, or another party billing an item the physician also billed.

Correct Answer: claim denial rate

OIG guidance states that a practice can improve documentation quality by comparing its claim denial rate with the rates of other practices in the same specialty, to the extent the carrier can supply that information. Option a is incorrect because internal audit results are listed among the primary compliance documents a practice would retain, not a figure the guidance has practices compare with peers. Option b is incorrect because gift and gratuity standards belong to the improper inducements risk area under the anti-kickback statute, not to documentation quality benchmarking. Option d is incorrect because a retention schedule addresses how long documents are kept, which the guidance treats as a separate records topic rather than a benchmark against other practices.

Correct Answer: Remuneration given to induce Federal program business

The anti-kickback statute provides criminal penalties for knowingly offering, paying, soliciting, or receiving bribes, kickbacks, or other remuneration to induce business reimbursable by Federal health care programs, which matches payments tied to ordering from a supplier. Option b is incorrect because support for claim codes in the medical record is an internal documentation guideline, which belongs to the documentation risk area rather than to kickbacks. Option c is incorrect because comparing denial rates with other practices in the same specialty is a method for improving documentation quality, not a feature of the anti-kickback statute. Option d is incorrect because completeness and legibility of the medical record are documentation standards, and they say nothing about payments offered in exchange for ordering or referring business.

Correct Answer: The practice's needs, specialty and size

OIG guidance states that, ideally, education programs will be tailored to the physician practice's needs, specialty and size, and will include both compliance and specific training under Step Four. Option a is incorrect because payer standards and procedures are a reason to revise the compliance program, but they are not the stated basis for tailoring education. Option b is incorrect because the guidance does not tie education to payer mix or claim volume; it names the practice's own needs, specialty and size as the basis for tailoring. Option c is incorrect because an outsourced officer is discussed as a oversight option with limits such as accessibility, not as the factor that shapes how education is tailored.

Correct Answer: reaction to and solution for the issue

OIG guidance says that records showing how a problem was identified are as important as records tracking the practice's reaction to, and solution for, the issue. Both parts of the audit trail should be preserved. Option a is incorrect because sample selection is a separate audit step, covering random sampling from all claims, one payor, or risk areas, and is not the record paired with identification. Option b is incorrect because how often to run a focused review is a decision made when problems are found; it is not the information the guidance says to preserve. Option d is incorrect because training is something audit results may feed into when they reveal a need for more information, but the guidance does not pair it with identification records.

Correct Answer: Whom to turn to for assistance

OIG guidance recognizes that protecting anonymity may not be feasible in small practices. It still expects every employee to know whom to turn to with questions or reports, and to do so without fear of retribution. Option a is incorrect because OIG guidance presents the anonymous drop box as an example for larger practices, so small practices are not expected to rely on it. Option b is incorrect because communication with a billing company's compliance contact applies only if a billing company is used, and it concerns coordinating activities rather than employee reporting. Option c is incorrect because hotlines are described as formal, costlier measures that suit small practices poorly, and the guidance favors an open door policy and less formal communication instead.

Correct Answer: It reduces the program's authority and credibility

OIG guidance states that inaccurate or unreliable policies and procedures reduce the compliance program's authority, credibility, and effectiveness, and that documents not up to date diminish credibility with users and Government regulators. Option a is incorrect because the code of conduct is a separate tool for mission and ethical standards; the guidance only suggests reviewing it at leadership change, not because policies are stale. Option b is incorrect because the guidance links outdated documents to lost credibility with users and regulators, and does not describe any mandatory disclosure resulting from them. Option d is incorrect because the guidance gives the compliance officer a duty to ensure policies are created, coordinated, and maintained, but does not say outdated documents move liability to that role.

Correct Answer: A single compliance officer without a department

OIG guidance states that large organizations are unlikely to succeed with a single compliance officer and will likely need a department of compliance personnel. Deputy, regional and facility roles are the listed structures. Option b is incorrect because regional compliance officers covering the various geographic regions the organization serves are named as a structural option for large entities. Option c is incorrect because the guidance expressly lists deputy compliance officers responsible for areas such as audits, investigations, training and policies as a way to organize staff. Option d is incorrect because the guidance describes facility compliance officers or liaisons responsible for a specific facility or location as one option for organizing the department.

Correct Answer: Provide several independent reporting paths, including one anonymous path

OIG guidance says the Compliance Committee should develop several independent reporting paths so reports cannot be diverted by supervisors, and it should not require personnel to go to a supervisor first. At least one path should permit anonymous reporting. Option a is incorrect because screening by a department head recreates the diversion risk; guidance wants reports that supervisors and other personnel cannot divert or intercept. Option b is incorrect because guidance calls for several paths, and at least one must be independent of business and operational functions and allow anonymous reports; one email channel falls short. Option c is incorrect because guidance says the entity should not deter reporting by requiring personnel to bring concerns to a manager first, and training does not change that.

Correct Answer: Monthly screening of the LEIE and State Medicaid exclusion lists

OIG guidance lists monthly screening of the LEIE and State Medicaid exclusion lists as an example of routine monitoring of known risks. Other examples are regular screening of State licensure and certification databases and annual review of policies and procedures. Option b is incorrect because the risk assessment is a separate process for identifying, analyzing and responding to risk; its results drive the audit schedule rather than being listed as routine monitoring. Option c is incorrect because guidance directs the Compliance Committee to review other incentive plans, but it does not list this review among its examples of routine monitoring of known risks. Option d is incorrect because guidance describes this as a trigger for an additional audit based on risks identified during the year, not as a routine monitoring example.

Correct Answer: Post information on how to access the OIG Hotline

OIG recognizes that protecting anonymity may not be feasible for small entities. Those entities, particularly where anonymity is not possible, should post information about how to access the OIG Hotline in physical or virtual common areas. Option a is incorrect because the guidance still expects policies requiring good faith reporting of compliance issues, even where no formal disclosure program exists and anonymity is limited. Option b is incorrect because OIG recognizes anonymity may not be feasible and says the entity should make clear that a reporter's identity may become known or be revealed. Option c is incorrect because OIG states that a formal disclosure program may not be necessary or appropriate for a small organization, so it is not the step tied to anonymity limits.

Correct Answer: A more accurate view of employee behavior

OIG guidance lists, among the benefits of a compliance program for a clinical laboratory, providing a more accurate view of employee behavior relating to fraud and abuse. The other choices misstate other points in the guidance. Option a is incorrect because OIG recognizes that a program may not entirely eliminate fraud, abuse and waste; it says an effective program significantly reduces the risk of improper conduct. Option c is incorrect because the guidance describes a centralized source for distributing information on health care statutes, regulations and program directives, not contract rates, and that benefit concerns information rather than employee conduct. Option d is incorrect because OIG states no single best laboratory program exists given the diversity of laboratories, so this cannot be a benefit the guidance lists.

Correct Answer: It may be modified and expanded

The OIG states that, as appropriate, the clinical laboratory guidance may be further modified and expanded as the OIG obtains more information and knowledge. The guidance is therefore not fixed and remains open to revision. Option a is incorrect because the guidance states its elements can be used by all clinical laboratories regardless of size, location or corporate structure, with attention to small laboratories too. Option b is incorrect because the guidance is presented as OIG suggestions and a voluntary set of guidelines, and nothing in it says it converts into a binding rule. Option d is incorrect because the Model Compliance Plan was an earlier OIG document that was considered in drafting this guidance, so it is a predecessor and not a successor.

Correct Answer: Contact the provider for clarification or resolution

OIG guidance tells billing company personnel to maintain an open dialogue with providers on documentation issues. When documentation is ambiguous or conflicting, they should contact the provider for clarification or resolution. Option a is incorrect because the guidance calls for an open dialogue with providers on documentation issues, which is the opposite of ending the relationship over unclear paperwork. Option c is incorrect because submitting first skips the step the guidance sets out; written policies are to include a methodology for resolving ambiguities in the provider's paperwork before the claim goes out. Option d is incorrect because the guidance describes no step of choosing a code by reimbursement level; it directs personnel to seek clarification instead of resolving the ambiguity by assumption.

Correct Answer: The provider and the health care program

OIG guidance for billing companies says they should institute procedures providing for timely and accurate reporting of overpayments to both the provider and the health care program, because the provider owes the refund. Option a is incorrect because governing body members are addressed in the guidance on standards of conduct, and the overpayment reporting procedures do not name them as recipients. Option b is incorrect because a beneficiary appears in the guidance only as a possible party to a duplicate payment, not as a recipient of the overpayment reports. Option d is incorrect because the guidance names the provider and the health care program as the two recipients, and a clearinghouse is not among the parties listed.