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

Correct Answer: Tell physicians that claims are paid only for services that are covered, reasonable, and necessary

OIG guidance says laboratory compliance programs should communicate to physicians that claims will only be paid if the service is covered, reasonable, and necessary for the beneficiary given his or her clinical condition. Option b is incorrect because a laboratory should be able to produce or obtain documentation supporting medical necessity upon request, which an order alone would not provide. Option c is incorrect because OIG recognizes that physicians or other authorized individuals must be able to order any tests they believe appropriate for treatment, so the laboratory cannot restrict ordering. Option d is incorrect because the guidance states that laboratories do not and cannot treat patients or make medical necessity determinations, so that role stays outside the laboratory.

Correct Answer: The compliance committee

OIG guidance says the compliance officer should ascertain patterns that require a change in policy and forward these issues to the compliance committee to remedy the problem. The committee is the designated recipient. Option a is incorrect because financial management receives assistance with internal compliance review and monitoring activities, including periodic department reviews, which is support work rather than the body that receives pattern issues. Option c is incorrect because they may take part in corrective action when appropriate, yet guidance does not name them as the recipient of policy-change issues found by the officer. Option d is incorrect because OIG guidance gives that office a narrower task: coordinating personnel issues so providers and employees do not appear in the Cumulative Sanction Report, not remedying billing patterns.

Correct Answer: Reasonable and prudent background investigation, including a reference check

OIG guidance says billing companies should conduct a reasonable and prudent background investigation, including a reference check, for new employees with discretionary authority over compliance decisions or compliance oversight. The application should also require disclosure of criminal convictions or exclusion actions. Option a is incorrect because oral warnings are the mildest sanction in the disciplinary range for noncompliance, not a screening step applied to a new applicant. Option b is incorrect because hotlines let existing employees report suspected violations anonymously; they are a reporting channel and play no part in investigating a candidate's background. Option c is incorrect because annual professional training is recommended for coding personnel on updated codes and belongs to education, not to the application and screening process.

Correct Answer: I and II

OIG guidance calls for written confidentiality and non-retaliation policies distributed to all employees, and for training that makes staff knowledgeable about procedures for alerting senior management to problems and concerns. Statements I and II are accurate. Option b is incorrect because statement III reverses OIG guidance, which recommends that attendance and participation in training be made a condition of continued employment, not left optional. Option c is incorrect because statement IV conflicts with the guidance that a billing company maintain its newsletters in a central location, so new employees can see guidance previously provided. Option d is incorrect because both statements contradict the guidance, and this pairing also leaves out the accurate statements on confidentiality and non-retaliation policies and on procedures for alerting senior management.

Correct Answer: Disciplinary actions imposed on responsible staff

OIG guidance lists five items for the payor: voluntary program statement, circumstances, methodology, claim-specific information and amount. Disciplinary actions are a compliance program review element, not refund information, so they are the item NOT provided. Option a is incorrect because informing the payor that the refund is made pursuant to a voluntary compliance program is the first listed item of information. Option b is incorrect because a description of the complete circumstances behind the overpayment is among the listed items the payor receives. Option c is incorrect because the guidance lists the method by which the overpayment was determined as one of the items to give the payor.

Correct Answer: I, II, and IV

OIG guidance says Medicare pays only for services that are covered, reasonable, and necessary. The laboratory must be able to produce or obtain supporting documentation on request. Laboratories do not and cannot treat patients or make medical necessity determinations. Option a is incorrect because it leaves out statement IV, which is also accurate because the guidance says laboratories do not and cannot treat patients. Option c is incorrect because it includes statement III, but OIG guidance says laboratories cannot make medical necessity determinations, so that role is not the laboratory's. Option d is incorrect because it keeps statement III, which assigns the necessity determination to the laboratory, and drops statement I, the standing payment condition of covered, reasonable, and necessary.

Correct Answer: Extended the diagnostic code requirement to non-physician practitioners

Section 4317(a) amended the Social Security Act provisions on diagnostic codes for physician services by adding the practitioners specified in the statute, so non-physician practitioners fall under the same requirement as physicians. Option a is incorrect because the mammography exception sits in the Medicare ordering regulation and lets a qualified interpreting physician order without treating the beneficiary; the statute addresses diagnostic information. Option b is incorrect because verifying ambiguous orders before billing is laboratory compliance guidance on standing orders, not a feature of the statutory amendment on diagnostic information. Option d is incorrect because that is the treating physician rule in the Medicare regulation on ordering diagnostic tests, which is separate from the statute's diagnostic information requirement.

Correct Answer: It supplements the earlier guidance

OIG published the Supplemental CPG to add new compliance recommendations and an expanded discussion of risk areas to its prior hospital guidance. It supplements the original guidance rather than replacing it. Option b is incorrect because some commenters preferred a replacement CPG, but OIG chose a concise supplement for efficiency instead of replacing the original hospital guidance. Option c is incorrect because clinical laboratories received the first compliance guidance, while the supplemental guidance is directed to hospitals and hospital systems. Option d is incorrect because OIG describes both documents as voluntary guidelines, and the suggestions in compliance program guidances are not mandatory for hospitals.

Correct Answer: The seven steps of the Federal Sentencing Guidelines

OIG guidance states that the recommended elements are based on the seven steps of the Federal Sentencing Guidelines. The clinical laboratory model and corporate integrity agreements are described only as similar to the elements. Option a is incorrect because the guidance describes the elements only as similar to this earlier OIG model, not as built on it. Option b is incorrect because OIG took these earlier publications into account while drafting the guidance, and they inform risk areas rather than serve as the foundation of the elements. Option d is incorrect because these are named as a comparison point, since the elements resemble them, but the guidance does not say the elements derive from them.

Correct Answer: Corporate ethics

OIG guidance says hospitals should require training in corporate ethics, which emphasizes the organization's commitment to compliance with legal requirements and policies. It is listed separately from training in statutes, regulations, guidelines and private payor policies. Option b is incorrect because OIG guidance lists this as a separate training area, and the emphasis on organizational commitment is assigned to training in corporate ethics instead. Option c is incorrect because the guidance names private payor policies as their own subject, listed next to statutes and regulations, apart from the ethics training that stresses commitment. Option d is incorrect because the guidance places this among the session subjects with the compliance program overview, fraud and abuse laws and coding requirements; corporate ethics carries the commitment emphasis.

Correct Answer: Response team

OIG guidance asks whether the hospital has created a response team, with representatives from the compliance, audit, and other relevant functional areas, that can evaluate detected deficiencies quickly. Option a is incorrect because senior management may resolve some disciplinary matters and discover misconduct, but the guidance does not assign it the quick evaluation of detected deficiencies. Option b is incorrect because the guidance names this body among those that may discover credible evidence of misconduct, not as the group formed to evaluate detected deficiencies quickly. Option c is incorrect because peer review procedures are mentioned only in connection with privilege revocation as a disciplinary action, not as a body for evaluating deficiencies.

Correct Answer: They are viewed as relatively well-understood risks within the industry.

OIG describes upcoding, unbundling, and similar claim risks as common and longstanding. Because they are relatively well-understood in the industry, the discussion instead highlights evolving or under-appreciated risks, though hospitals should stay vigilant about the familiar ones. Option b is incorrect because nothing in the guidance moves them to another document; it keeps them as risks hospitals must stay vigilant about, while cost report falsity is listed as its own item. Option c is incorrect because the guidance still lists them among common and longstanding claims risks, and it states that knowing submission of a false claim is actionable under the False Claims Act. Option d is incorrect because evolving or under-appreciated risks are what the discussion does highlight, whereas upcoding and unbundling are described as common and longstanding, which is the opposite.

Correct Answer: Potential to skew clinical decision-making

OIG guidance says courts have identified aggravating considerations for arrangements meeting both anti-kickback tests. One asks whether the arrangement could interfere with, or skew, clinical decision-making, alongside increased costs and overutilization risk. Option a is incorrect because this is the third part of the Stark law inquiry, a separate analysis, and not an anti-kickback aggravating consideration. Option b is incorrect because a fair market value payment does not legitimize remuneration when an illegal purpose also exists, so it is not an aggravating consideration. Option d is incorrect because paperwork is not listed as an aggravating consideration; for Stark exceptions, the actual relationship between the parties matters more than the documents.

Correct Answer: The market rate may be distorted

OIG guidance warns that when fair market value rests on comparables, the hospital should ensure the comparable market rate is not distorted. A market where physicians control all providers, such as ancillary services, may be distorted. Option b is incorrect because selection based on past or anticipated referrals is its own question and concerns how participants were chosen, not how the comparable rate was built. Option c is incorrect because documentation is a separate review question; nothing in this situation suggests the arrangement is missing a written agreement or service records. Option d is incorrect because linkage to Federal health care program reimbursement is a different factor; physician control of a comparable market says nothing about how payment is calculated.

Correct Answer: The policy conflicts with EMTALA because services must be provided despite diversionary status.

OIG guidance states that when an ED is on diversion and an individual comes for evaluation or treatment, the hospital is required to provide those services despite its diversionary status. Turning individuals away conflicts with EMTALA. Option a is incorrect because the guidance frames the duty around individuals who come to the emergency department, with no limit based on how they arrive. Option b is incorrect because OIG guidance states the hospital must still provide evaluation or treatment when an individual comes to the ED, so diversion does not suspend the duty. Option c is incorrect because screening or treatment of an emergency medical condition cannot be delayed to ask about payment method or insurance status, so this step adds a further violation.

Correct Answer: Whether the remuneration is likely to influence the beneficiary's selection of a particular provider

The key inquiry under the CMP is whether the hospital knows or should know the remuneration is likely to influence the beneficiary to select a particular provider, practitioner, or supplier for Medicare or Medicaid payable services. Option b is incorrect because bad debt treatment appears only as a condition of the safe harbor for inpatient cost-sharing waivers, not as the test for gifts and gratuities. Option c is incorrect because collecting cost-sharing is a separate general obligation of hospitals, and the guidance does not frame it as the central test for gifts under the CMP. Option d is incorrect because a Medicare SELECT plan is mentioned only as an exception to the third party payer agreement limit within the cost-sharing waiver safe harbor.

Correct Answer: Anonymous hotline

OIG guidance on developing open lines of communication asks whether the hospital established an anonymous hotline or similar mechanism so staff, contractors, patients, visitors and medical and clinical staff can report potential compliance issues. Option a is incorrect because it is a policies and procedures factor used to identify weaknesses and risks in operations, and it does not give anyone a way to report concerns. Option b is incorrect because the standards of conduct fall under policies and procedures, where the guidance asks whether they were distributed to directors, officers, managers, employees, contractors and clinical staff. Option d is incorrect because such a group carries out special missions, such as conducting an investigation or evaluating a proposed program enhancement, rather than receiving reports from staff and visitors.

Correct Answer: Billing for services of an excluded employee

Federal fraud and abuse guidance lists billing for services performed by an employee excluded from participating in federal health care programs as an improper claim example. It sits alongside unqualified or improperly supervised staff, and it turns on who performed the service. Option b is incorrect because it describes codes reflecting a more severe illness or more expensive treatment than was provided, so it turns on code selection rather than who delivered care. Option c is incorrect because it covers claims for care that never happened, so the issue is whether the service occurred, not the status of the performer. Option d is incorrect because it means billing separately for services already included in a global fee, such as an E/M service the day after surgery, which concerns fee packaging.

Correct Answer: Refund provisions apply to both assigned and unassigned claims

All suppliers who sell or rent medical equipment and supplies to Medicare beneficiaries are subject to the refund provisions, whether accepting assignment or not. The provisions cover both assigned and unassigned claims. Option a is incorrect because without a proper ABN before receipt of the item, the guidance leaves the beneficiary with no financial responsibility, which is what triggers the refund. Option b is incorrect because physician refunds fall under a separate provision; DMEPOS rules cover every supplier who sells or rents medical equipment and supplies to beneficiaries. Option d is incorrect because the guidance says suppliers are subject to the refund provisions whether accepting assignment or not, so declining assignment gives no exemption.

Correct Answer: Undocumented services are treated as not done

CMS guidance applies the saying "If you didn't document it, it's the same as if you didn't do it" to Medicare billing. Documentation must support the claims submitted, so a billed service without a record entry is unsupported. Option a is incorrect because documentation must support the claim as submitted, and the guidance has a billing company ask the provider for clarification instead of supplying support itself. Option c is incorrect because the guidance says other providers rely on a physician's records for medical history; it does not allow their records to establish services the physician billed. Option d is incorrect because modifier 25 is described as an upcoding risk for a separately identifiable E/M service on the same day as a procedure, not a substitute for documentation.