AAPC-CPCO Certified Professional Compliance Officer - Set 3 - Part 1

Correct Answer: As overpayments recoverable from the provider or other person

The statute provides that indemnification payments by the Secretary are deemed made to the provider or other person who furnished the items or services. They are treated as overpayments and are recoverable from that party under applicable law. Option b is incorrect because the statute expressly classifies these payments as overpayments, which makes them recoverable under applicable provisions of law rather than shielded from recovery. Option c is incorrect because the statute deems indemnification payments made to the provider or other person, so recovery runs against that party and not against the individual who was indemnified. Option d is incorrect because the statute states that an item or service for which an individual is indemnified is not taken into account in applying any limitation on payment.

Correct Answer: Precluded from collecting funds from the beneficiary

When a notifier knew or should have known Medicare would not pay and fails to issue a required ABN or issues a defective one, the notifier is precluded from collecting funds from the beneficiary and must refund promptly. Option a is incorrect because prompt refunds are required for funds previously collected, and a failure to refund promptly may result in sanctions. Option c is incorrect because that charge applies only when the beneficiary received a properly delivered ABN and agreed to pay, which is not the situation described. Option d is incorrect because collection from the beneficiary is barred when the ABN is missing or defective, so no fee schedule amount can be billed to the beneficiary.

Correct Answer: Claim for a pattern of such services

The statute lists a claim for a pattern of medical or other items or services that a person knows or should know are not medically necessary as a separate ground for civil monetary penalties. Option a is incorrect because the statute treats this as a licensing problem, covering a service furnished or supervised by someone not licensed as a physician, not a medical necessity problem. Option b is incorrect because this ground concerns a person excluded from the Federal health care program, which turns on program status rather than on whether the services were medically necessary. Option d is incorrect because this ground addresses items or services that were not delivered as billed, which is a question of accuracy, not of necessity.

Correct Answer: Experimental laboratory tests

Experimental items or services, such as investigational-use-only laboratory tests, are denied as not reasonable and necessary, not as categorical exclusions. For these, the beneficiary must be given an ABN. Option a is incorrect because they are listed among categorical denial examples and among care explicitly excluded under the Act, so they fall within the set named. Option c is incorrect because it is named as a categorical denial example under a statutory provision, so it belongs to the never-covered group. Option d is incorrect because they appear in the list of categorical denial examples, based on a statutory provision outside the limitation on liability rules.

Correct Answer: Plan of care

OIG guidance lists the plan of care among the items documented for each patient encounter, alongside the reason for the encounter, relevant history, examination findings, prior diagnostic test results, assessment, and the date and legible identity of the observer. Option a is incorrect because the guidance ties destruction of documents to a records retention system covering creation, distribution, retention, and destruction, not to the contents of an encounter record. Option b is incorrect because the guidance raises joint ventures in its discussion of the anti-kickback statute and physician self-referral law, and does not list them among encounter documentation elements. Option c is incorrect because the guidance presents it as a quality-improvement comparison against other practices in the same specialty, not as an item in the list of encounter documentation elements.

Correct Answer: certificates of medical necessity

OIG billing company guidance lists documentation that supports the standards of medical necessity, giving certificates of medical necessity for DMEPOS and home health services as the example. The other choices are separate elements of proper documentation. Option b is incorrect because dated and authenticated records are a separate documentation element in the guidance's list, not the example given for medical necessity standards in DMEPOS and home health. Option c is incorrect because a documented treatment plan is its own listed element of proper documentation and is not the medical necessity example tied to DMEPOS and home health services. Option d is incorrect because this is a distinct listed item about test results being addressed in the physician's documentation, with no link to DMEPOS or home health medical necessity.

Correct Answer: Alteration of the documentation

OIG guidance lists alteration of the documentation as its own risk area for billing companies that provide coding services. Rewriting a provider's note to fit a chosen diagnosis changes the medical record itself, which is that risk. Option a is incorrect because it concerns who is hired to work for the billing company, and the scenario describes what a coder did to a record. Option c is incorrect because it refers to coding a diagnosis or procedure without supporting clinical documentation, not to changing the content of an existing provider note. Option d is incorrect because this area covers periodic review of practices, including software edits, for consistency with Federal, State and private payor requirements, not a coder editing a provider's record.

Correct Answer: Only services actually provided

OIG compliance guidance for hospitals directs that, for all claims submitted on behalf of teaching physicians, only services actually provided may be billed. Documentation and presence requirements support this principle. Option a is incorrect because the guidance requires documentation signed by the physician who provided or supervised the service, so resident-only documentation does not define what may be billed. Option b is incorrect because the guidance ties billing to services actually provided and to physicians who provide or supervise them, not to supervision by any staff member. Option c is incorrect because that phrase comes from the incident to conditions for office services and supplies, which are a separate topic from teaching physician billing.

Correct Answer: Resalable or re-rentable items

Under the supplier's right to recover resalable items, Medicare rules do not prohibit a supplier that made a proper refund from recovering items that are resalable or re-rentable from the beneficiary. Option a is incorrect because suppliers are strongly discouraged from recovering consumable goods, so Medicare guidance does not treat them as the items a supplier may properly take back. Option b is incorrect because a missing supplier number is only an example of a circumstance precluding payment, which may be cured so a new claim can follow; it does not define recoverable items. Option d is incorrect because goods in poor condition fall into the group where recovery is strongly discouraged, because they could not be sold or rented again.

Correct Answer: State escheat laws

OIG billing company guidance directs billing companies to State escheat laws for the specific requirements on notifications, time periods and payment of any unclaimed funds that arise from credit balances. Option b is incorrect because the statute defines obligations and knowing conduct for retained overpayments, but the guidance does not point to it for unclaimed funds notices, time periods or payment. Option c is incorrect because private and public plan rules are listed among the documents a records system must keep, and the guidance does not name them for unclaimed funds. Option d is incorrect because these govern the creation, storage and destruction of documents in a billing company's records system, not how unclaimed funds are handled.

Correct Answer: Obtaining patient consent before refunding

The statute requires a person to report and return the overpayment to the proper recipient and to notify that recipient in writing of the reason. It sets no requirement to obtain patient consent before refunding. Option a is incorrect because the statute directs the person to report the overpayment to the appropriate government recipient at the correct address, so this is a stated duty. Option b is incorrect because paragraph (1)(B) requires written notice of why the overpayment occurred, sent to whoever received the returned funds, so it is a statutory requirement. Option d is incorrect because returning the overpayment to the Secretary, State, intermediary, carrier, or contractor, as appropriate, is the other half of the core duty in paragraph (1)(A).

Correct Answer: They are satisfied through the protocol's disclosure process

The CMS regulation provides that a person satisfies the reporting obligations by making a disclosure under the OIG's Self-Disclosure Protocol or the CMS Voluntary Self-Referral Disclosure Protocol that results in a settlement agreement, following that protocol's process. Option a is incorrect because the regulation requires contractor processes such as credit balance reporting except where a protocol disclosure resulting in a settlement agreement applies, which satisfies the obligations directly. Option b is incorrect because that suspension covers investigating related overpayments and ends at the earlier of the investigation's conclusion or 180 days; it does not describe a settlement outcome. Option c is incorrect because the cost report reconciliation provision only defers returning overpayments tied to updated SSI ratio information or an outlier reconciliation, and it has no link to protocol settlements.

Correct Answer: Limitation On Liability

The Limitation On Liability provisions apply to all Part A services and all assigned claims for Part B services. An assigned Part B physician claim denied on a specified statutory basis falls under them. Option a is incorrect because they cover unassigned claims for physicians' services, and this provider accepted assignment, so that provision does not fit the claim. Option c is incorrect because Medicare guidance states that refund requirements do not apply to Part A claims, and this claim is a Part B service. Option d is incorrect because they address assigned and non-assigned claims for equipment and supplies, which is a different category from a physician service.

Correct Answer: Beneficiary, provider, or supplier may appeal coverage and liability

The Medicare manual states that the beneficiary, healthcare provider, or supplier has the right to appeal both the issue of coverage for the claim and the determination of liability. Option a is incorrect because the manual extends the appeal right to both the issue of coverage for the claim and the determination of liability, not liability alone. Option b is incorrect because a formal finding of fraud or abuse removes the provider's or supplier's liability protection and results in an immediate liability finding; the manual does not state that it ends appeal rights. Option d is incorrect because the manual gives the right to appeal to the beneficiary, healthcare provider, or supplier, so appeal rights are not limited to the beneficiary.

Correct Answer: Refund owed to the beneficiary promptly

A notifier who knew or should have known Medicare would not pay and fails to issue a required ABN is likely financially liable, cannot collect from the beneficiary, and must make prompt refunds of funds already collected. Option b is incorrect because liability shifts to the beneficiary only when a properly delivered ABN exists and the beneficiary agrees to pay; here no notice was given. Option c is incorrect because protection is possible only when the notifier shows it did not know and could not reasonably have been expected to know Medicare would not pay. Option d is incorrect because the notifier is precluded from collecting from the beneficiary in this situation, so no amount, including a fee schedule limit, may be kept.

Correct Answer: Issue the ABN before delivering the care

Under the ABN triggering events, a reduction does not by itself require an ABN. If the beneficiary wants care no longer considered medically reasonable and necessary, the ABN must be issued prior to delivering that non-covered care. Option a is incorrect because the guidance states a reduction alone does not require an ABN, but when the beneficiary wants care no longer reasonable and necessary, the ABN must be issued. Option b is incorrect because the triggering event here is a reduction where the beneficiary wants continued non-covered care, so the notice is due before that care is delivered. Option c is incorrect because that form is reserved for Part A skilled nursing facility items and services, and this scenario involves outpatient therapy under Part B.

Correct Answer: The reason payment is likely to be denied

OIG guidance states that an ABN must be in writing, clearly identify a particular service, state that payment likely will be denied, and give the reason(s) for the belief that payment is likely to be denied. Option a is incorrect because a physician acknowledgment is a separate laboratory practice for customized profiles, and the ABN is signed by the beneficiary who agrees to pay. Option b is incorrect because routine notices that only say denial is possible are not accepted as evidence of advance notice, since the notice must state that denial likely will occur. Option d is incorrect because the notice must clearly identify one particular service, so a general list of laboratory services would not meet the content standard.

Correct Answer: Medical necessity partial denial

A medical necessity partial denial is the denial of coverage for the unnecessary component of a covered item or service when that component exceeds the beneficiary's medical needs. The excess is not reasonable and necessary under the Act. Option a is incorrect because this denial arises when the supplier lacks a supplier number, which concerns the supplier's eligibility rather than an excess item component. Option b is incorrect because this denial results when a supplier violates the statutory prohibition on unsolicited telephone contacts, and it applies to all equipment and supplies equally. Option c is incorrect because limitation on liability is the section 1879 protection that still applies to assigned claims denied as not reasonable and necessary, not a denial of an excess component.

Correct Answer: No financial responsibility

Under the DMEPOS refund provision, if a proper ABN is not issued before the beneficiary receives a covered equipment or supply item and the provisions apply, the beneficiary has no financial responsibility. Option a is incorrect because the manual removes liability from the beneficiary when no proper ABN precedes the item, so billing the full charge to the beneficiary is not permitted. Option b is incorrect because the refund provisions cover both assigned and unassigned claims, so the assignment status does not shift liability back to the beneficiary. Option d is incorrect because the guidance states the beneficiary has no financial responsibility at all, which leaves no room for collecting cost-sharing amounts from the beneficiary.

Correct Answer: The hospital to which the patient was transferred

Under the Medicare regulations on transfers between PPS hospitals, only the hospital to which the patient was transferred may charge the full DRG. The transferring hospital charges Medicare only a per diem amount. Option b is incorrect because the regulation does not split the DRG; full DRG charging belongs to a single hospital, and the other is held to a per diem. Option c is incorrect because the regulation gives no choice between facilities; it names one hospital for the full DRG and sets a different charge for the other. Option d is incorrect because the regulation limits the transferring hospital to charging Medicare only a per diem amount, not the full DRG.