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

Correct Answer: Concentrate first on the areas of coding and billing that have caused trouble for the practice

OIG guidance says initial development of a compliance program can focus on practice risk areas that have been problematic, such as coding and billing, examining claim denials and repeated overpayments and correcting their most frequent sources. Option a is incorrect because free compliance oversight or claims review from a referral source would implicate the anti-kickback and Stark self-referral laws; fair market value payment is expected. Option b is incorrect because the guidance ties initial development to risk areas that have been problematic for the practice itself, examined through its own denials and repeated overpayments. Option d is incorrect because the guidance describes implementation as a multi-tiered process and leaves the extent of each measure to the practice, so full simultaneous implementation is not required.

Correct Answer: Whether individuals are properly carrying out their responsibilities

Step One describes an ongoing evaluation that asks whether individuals are properly carrying out their responsibilities. Staff members skipping assigned compliance tasks is a finding about exactly that aspect of the evaluation. Option a is incorrect because OIG guidance leaves the manner and extent of implementing voluntary measures to the practice, so this is not an aspect of the evaluation. Option c is incorrect because that is a separate listed aspect focused on the claims, while the finding describes staff performance of assigned compliance duties. Option d is incorrect because that aspect concerns the written standards and procedures themselves, not whether staff members carry out the tasks assigned to them.

Correct Answer: Ongoing evaluation of the compliance program

The policy describes the ongoing evaluation process of Step One: Auditing and Monitoring. It tests whether standards and procedures are current and accurate, whether individuals carry out their responsibilities, and whether claims are submitted appropriately. Option a is incorrect because it is one possible response once an overpayment has been found, so it addresses a later step rather than the ongoing evaluation described. Option b is incorrect because it is a follow-up the practice considers after problems are identified, not the general check of standards, responsibilities and claims the policy describes. Option d is incorrect because this is a method for choosing which claims to audit, and the policy says nothing about how claims or services are drawn for review.

Correct Answer: Claims reimbursed by Federal health care programs

OIG guidance recognizes that a broad audit may be burdensome for some physician practices, so at a minimum it encourages a review of claims reimbursed by Federal health care programs. Option b is incorrect because choosing all claims from a particular payor is one way to define the universe for a random sample, but OIG guidance does not set it as the minimum. Option c is incorrect because risk areas are another method for building the universe of claims to sample, not the baseline review OIG encourages when a broader audit is burdensome. Option d is incorrect because denial history helps a practice focus its initial development on problem areas such as coding and billing, but it is not the minimum audit.

Correct Answer: Internal audit identifying risk areas

OIG guidance states that after the internal audit identifies the practice's risk areas, the next step is to address them through written standards and procedures, which reduce erroneous claims and fraudulent activity. Option a is incorrect because a focused review is described as a possible later step, decided when problems are identified, and not as the event that leads into the standards. Option b is incorrect because the guidance says audit results may be analyzed for incorporation into training, so training follows audit findings and does not come before the standards step. Option c is incorrect because the guidance treats an appropriate response as a component of the audit protocol after a problem is found, not as the lead-in to Step Two.

Correct Answer: OIG Work Plan

OIG guidance directs practices seeking more information on potential risk areas to the OIG Work Plan, which identifies vulnerabilities and risk areas on which the OIG will focus in the future. Option a is incorrect because these are the practice's own policy statements on patient care, personnel matters and legal compliance, not an OIG publication forecasting enforcement focus. Option c is incorrect because these reports describe program vulnerabilities and risk areas the OIG targeted during the preceding six months, so they look backward rather than ahead. Option d is incorrect because this is an internal audit method for drawing claims to review, and it reveals nothing about where the OIG will direct attention.

Correct Answer: Designate a liaison to the outsourced officer

OIG guidance suggests that the practice designate someone to serve as a liaison with the outsourced compliance officer. This maintains continual interaction and ensures a strong tie between the officer and the practice's daily operations. Option a is incorrect because record retention is a separate standards-and-procedures topic, and the guidance does not offer offsite storage as a way to connect an outsourced officer with daily operations. Option b is incorrect because a bulletin board is one training modality for educating staff, so it does nothing to link an outsourced officer with the practice's daily work. Option d is incorrect because serving several practices is named as a source of possible conflicts of interest, which is a limitation of outsourcing and not a remedy.

Correct Answer: Double billing

Double billing occurs when a physician bills for the same item or service more than once, resulting in duplicate payment. It can arise from simple error, but the repeated claim for one visit is still this risk area. Option b is incorrect because that risk area covers services never provided, such as laser surgery billed where no laser equipment existed, whereas this visit actually took place. Option c is incorrect because it concerns improper billing caused by using a provider identification number wrongly, and nothing in this scenario points to a problem with an identifier. Option d is incorrect because it involves presenting services the program does not cover as though they were covered, while the problem here is repetition of a claim, not coverage.

Correct Answer: Billing for non-covered services as if covered

OIG guidance for physician practices lists billing for non-covered services as if covered as the bullet immediately following double billing resulting in duplicate payment, within the coding and billing risk areas most frequently investigated and audited. Option a is incorrect because it appears later in the OIG list, following the risk area of knowing misuse of provider identification numbers that results in improper billing. Option b is incorrect because OIG places this risk area first in the list, ahead of double billing, and illustrates it with a physician billing for laser surgery he did not perform. Option c is incorrect because OIG lists this second, before double billing, and ties it to services not warranted by a patient's documented medical condition.

Correct Answer: Verification that the bill is accurate

OIG guidance states that documentation supports clinical patient care and, as a second function, serves as verification that the bill is accurate as submitted. This is why documentation is a key compliance risk area. Option b is incorrect because denial rate comparison is a method for improving documentation quality, used within the same specialty, and is not a function of the documentation itself. Option c is incorrect because referral relationships fall under the anti-kickback statute and self-referral law standards, a separate risk area from what a medical record documents for billing. Option d is incorrect because the guidance says no requirement exists to retain compliance records, so documentation does not authorize retention at billing time.

Correct Answer: Creation, distribution, retention, and destruction of documents

OIG guidance says a records retention system would establish standards and procedures regarding the creation, distribution, retention, and destruction of documents, giving the practice a defined approach to its compliance, business and medical records. Option a is incorrect because these are compliance activities whose resulting documents are retained; the guidance does not describe the records system as setting standards for performing them. Option b is incorrect because the guidance ties the records system to handling documents, not to the steps of the claims process, so this list describes a different function. Option d is incorrect because contract review is raised in the guidance in connection with anti-kickback and self-referral standards, not as the scope of a records retention system.

Correct Answer: Identity of the care giver

OIG guidance states that a properly documented medical record may validate the site of the service, the appropriateness of the services, the accuracy of the billing, and the identity of the care giver (service provider). Option a is incorrect because OIG guidance does not name payer finances among the validated points; the record supports the site, appropriateness, billing accuracy and care giver identity instead. Option b is incorrect because referral sources are tied to anti-kickback and self-referral concerns in OIG guidance, which does not list them among the points a medical record validates. Option c is incorrect because educational activities are compliance documents a practice would retain separately, not something a patient's medical record is described as validating.

Correct Answer: Voluntary, nonbinding guidance

OIG explains that it uses the word "should" in the GCPG to present voluntary, nonbinding guidance. The GCPG is voluntary and is not binding on any individual or entity. Option b is incorrect because OIG states that the GCPG is not binding on any individual or entity, so its wording cannot create a mandatory requirement. Option c is incorrect because the GCPG describes itself as a reference guide with voluntary guidance; nothing in that description turns the word into a measure of liability. Option d is incorrect because hyperlinked definitions apply to the unique defined terms in the GCPG, while OIG explains "should" separately as a way of presenting voluntary guidance.

Correct Answer: Distortion of medical decision-making

The guidance states that remuneration for referrals is illegal because it can distort medical decision-making. It also names overutilization of services or supplies and increased costs to Federal health care programs as harms. Option a is incorrect because the guidance says the opposite: remuneration for referrals can cause overutilization of services or supplies, not reduce it. Option b is incorrect because remuneration for referrals is said to increase costs to Federal health care programs, so a cost decrease reverses the stated concern. Option c is incorrect because claim denial rates appear in the guidance only as a benchmark for comparing documentation quality among practices, not as an effect of improper remuneration.

Correct Answer: conflict of interest

OIG guidance lists limitations of outsourced compliance officers, who spend most of their time offsite: lack of understanding of the practice's inner workings, accessibility, and possible conflicts of interest when one officer serves several practices. Option a is incorrect because a safe harbor defines arrangements not subject to the anti-kickback statute, so it concerns contracts and referrals rather than the limits of an offsite officer. Option c is incorrect because an annual training program is what the OIG recommends for individuals involved in coding and billing, which is an education step, not a drawback of outsourcing. Option d is incorrect because a records retention system sets standards for creating, distributing, retaining and destroying documents; it is a practice tool, not a limitation of an outsourced officer.

Correct Answer: Develop a corrective action plan

Under Step Five of OIG guidance, once a practice determines it has detected a possible violation, the next step is to develop a corrective action plan and determine how to respond to the problem. Option a is incorrect because a third-party billing company is mentioned only as a vendor the practice may work with on documentation adequacy, and it is not the response step. Option b is incorrect because maintaining updated manuals is advised as a reference resource for employees involved in billing, which is an ongoing education measure rather than the response to a detected violation. Option c is incorrect because outside seminars are described as one possible way to deliver training goals, not as the step the guidance names after a possible violation is detected.

Correct Answer: Integrating compliance into existing training

OIG guidance states that physician practices do not have to provide separate compliance and coding and billing training. In-service training and continuing education can integrate compliance issues and other core values, such as quality improvement and improved patient service. Option a is incorrect because OIG guidance treats an outsourced compliance officer as an oversight option with limits such as accessibility; the excerpt says nothing about handing the sessions to that person. Option b is incorrect because the policy describes in-service sessions run by the practice, and the third-party billing company is mentioned only as a partner for confirming documentation is adequate. Option d is incorrect because OIG recommends at least an annual training program for those involved in coding and billing, and continuous updates are only a supplement, not a replacement.

Correct Answer: Mandatory salary reduction for employees who report

OIG guidance lists reporting requirements, a simple reporting procedure, anonymity processes, and no retribution for good-faith reports. A mandatory salary reduction for reporting employees appears nowhere in that list and would contradict the no-retribution provision. Option b is incorrect because the guidance lists a requirement that employees report conduct a reasonable person would, in good faith, believe to be erroneous or fraudulent, so it is a listed feature. Option c is incorrect because the guidance includes provisions in the standards and procedures that there will be no retribution for reporting conduct believed in good faith to be erroneous or fraudulent. Option d is incorrect because standards and procedures are described as stating that a failure to report erroneous or fraudulent conduct is a violation of the compliance program.

Correct Answer: An anonymous drop box

OIG guidance lists a user-friendly reporting process as part of meaningful and open communication, giving an anonymous drop box as the example for larger practices. The other choices are informational or small-practice techniques. Option a is incorrect because it is a place where everyone in the practice can receive up-to-date compliance information, so it delivers information to staff rather than receiving reports. Option b is incorrect because these are a less formal technique for sharing compliance information in small practices, and they do not provide a channel for submitting reports. Option c is incorrect because OIG guidance presents it as a way a small physician practice may meet the communication element, not as the larger-practice reporting example.

Correct Answer: Providing a roadmap for relevant individuals

OIG guidance states that written policies and procedures give relevant individuals a roadmap outlining their duties, developing workflow management, imposing documentation requirements, defining oversight roles and implementing controls to mitigate entity-specific compliance risks. Option b is incorrect because that is Element 5 in the seven-element list, a separate element rather than the reason entities put duties and workflow into writing. Option c is incorrect because Element 7 covers what happens after an offense is detected; it does not describe outlining duties, workflow and oversight roles in advance. Option d is incorrect because this belongs to Element 4, which calls for informing personnel how to reach the compliance officer directly, not to the purpose of written policies.