AAPC-CPCO Certified Professional Compliance Officer - Set 3 - Part 2

Correct Answer: Reducing a refund by the individual's outstanding balance

The statute allows a refund to be reduced to the extent the individual owes an outstanding balance to the physician. This is a permitted adjustment, not a violation, so it is not a sanction basis. Option a is incorrect because the statute lists failure to comply with the refund requirement on a timely basis as a ground for sanctions. Option b is incorrect because failure to correct a billed but uncollected excess charge on a timely basis is expressly named as a sanctionable failure. Option c is incorrect because the statute names this repeated, knowing and willful conduct as the first ground for sanctions, so it is a valid basis.

Correct Answer: Recognized payment amount for nonparticipating physicians

The statute defines the limiting charge as a percentage of the recognized payment amount for nonparticipating physicians. Recognized payment amount is generally the fee schedule amount, so the ceiling is tied to the fee schedule rather than to billed charges. Option a is incorrect because State plan medical assistance appears in a separate provision on charges for beneficiaries eligible for Medicaid, not as the amount from which the limiting charge is calculated. Option b is incorrect because the statute builds the limiting charge from the recognized payment amount, so whatever the physician chooses to bill does not serve as the base. Option d is incorrect because prevailing charge appears only inside the older definition of recognized payment amount for nonparticipating physicians, and it is not the base for the limiting charge.

Correct Answer: Liable, because signing blank forms risks criminal, civil, and administrative penalties

OIG guidance treats signing blank certificates later completed with false information as an inappropriate certification. Knowing or reckless signing can lead to criminal, civil, and administrative penalties, with or without any personal benefit to the physician. Option b is incorrect because OIG guidance states physicians may be liable for false or misleading certifications even when they receive no financial or other benefit from suppliers. Option c is incorrect because anti-kickback exposure arises when compensation is received for a signature; here no benefit was received, yet liability still arises from the false certification itself. Option d is incorrect because the physician's signature supports the claims, and OIG guidance lists signing blank forms later completed falsely as an inappropriate certification, regardless of who filled in the content.

Correct Answer: A financial relationship

Under 42 CFR 424.22(d), a physician or allowed practitioner with a financial relationship with an HHA may not certify or recertify need for home health services, unless a section 1877 exception is met. Option a is incorrect because past referrals are not the stated trigger; the limitation applies when the physician holds a financial relationship with the HHA and no exception is met. Option b is incorrect because the regulation names no staff membership as a bar; it points instead to a financial relationship as defined in the referral-prohibition rules. Option d is incorrect because treating the patient earlier is not what the regulation restricts; the limit on certification functions turns on the physician's financial ties to the HHA.

Correct Answer: Giving them to patients free of charge

The guidance on free samples states that it is legal to give samples from drug and biologic companies to patients free of charge. Selling them is illegal, and billing Medicare for them draws federal prosecution. Option a is incorrect because the guidance directs physicians who accept samples to use reliable storage systems and keep samples separate from commercial stock, which this arrangement contradicts. Option b is incorrect because the federal government prosecutes physicians for billing Medicare for free samples, so reporting them as billable items invites enforcement rather than compliance. Option c is incorrect because the guidance states that giving samples to patients free of charge is legal but selling them is illegal, so this handling is unlawful.

Correct Answer: Each violation by the person

The civil penalties provision lets the Commissioner or the Secretary, pursuant to regulations, impose a civil money penalty against any person for each violation by that person of subsection (a), so the violation is the unit. Option b is incorrect because a fee appears only in the notice requirement for offers to help obtain free Social Security products; the penalty itself attaches to violations of subsection (a). Option c is incorrect because certification documents are addressed in the physician penalty provision of a different statute, which uses its own greater-of measure rather than the misuse-of-words penalty. Option d is incorrect because that per-individual unit belongs to the separate penalty for hospital payments that induce reduced or limited services, not to the misuse-of-words statute.

Correct Answer: Costs excluded from Federal program cost reports and claims

One condition of OIG's non-enforcement position is that transportation costs are not claimed directly or indirectly on any Federal health care program cost report or claim, and are not otherwise shifted to a Federal program. Option a is incorrect because OIG guidance requires that the transportation not include ambulance transportation, so adding it would take the program outside the conditions rather than satisfy any expense condition. Option c is incorrect because the conditions limit transportation to the hospital's or ambulatory surgical center's primary service area, which is a geographic restriction and says nothing about expense treatment. Option d is incorrect because the program must be offered uniformly to all patients of the hospital, so restricting eligibility conflicts with the uniform-availability condition and does not address expenses.

Correct Answer: Investors chosen for their ability to refer

OIG guidance lists investors being chosen because they are in a position to make referrals as a questionable feature in how investors are selected and retained, which may indicate a violation of the anti-kickback statute. Option a is incorrect because this is a shell laboratory indicator, which OIG guidance places under the nature of the business structure, not under investor selection and retention. Option b is incorrect because ownership of the DME and capital equipment by an existing entity describes a shell DME venture, a business structure feature. Option d is incorrect because responsibility for delivery and billing rests with the existing entity in a shell DME venture, so it reflects business structure rather than how investors are chosen.

Correct Answer: Payment of fair market value for the services

OIG states that when a referral source provides compliance services, the practice's payment of fair market value for those services generally addresses anti-kickback and Stark self-referral concerns, because free services could be seen as remuneration. Option a is incorrect because claims review is one of the services that implicates the anti-kickback and Stark laws when no fair market value is charged; OIG recommends training and education or policies and procedures instead. Option c is incorrect because documented rationale is advised for arrangements tracking, but it does not itself cure free compliance services; the guidance points to payment at fair market value. Option d is incorrect because oversight given free of charge is the very situation OIG names as implicating both laws, so it creates the concern rather than resolving it.

Correct Answer: Potential conflict of interest

OIG's key questions list this inquiry under potential conflicts of interest. A conflict of interest arises when self-interest interferes with an obligation to another person or organization, so objectivity of professional judgment is the test. Option a is incorrect because steering concerns directing patients or entities to a particular item, service, or health care entity, which is a separate key question from judgment objectivity. Option b is incorrect because that risk asks whether remuneration could lead to inappropriate utilization, a matter of Federal program impact rather than the objectivity of a person's judgment. Option c is incorrect because this inquiry looks at whether payment reflects an arm's-length price for services actually rendered, not whether judgment is or appears to be compromised.

Correct Answer: They typically involve a percentage payment, so the aggregate fee is not set in advance

OIG guidance explains that gainsharing typically involves a percentage payment, so the aggregate fee is not set in advance. The personal services safe harbor requires an advance-set aggregate fee, so protection is often unavailable. Option b is incorrect because the guidance describes gainsharing as a hospital-physician cost-savings arrangement and sets no emergency department limit; EMTALA is a separate topic with separate obligations. Option c is incorrect because OIG guidance lists efficiency, reduced waste and higher profitability as legitimate purposes of a properly structured arrangement, and does not cite them as the safe harbor obstacle. Option d is incorrect because OIG guidance names that attribution as part of what the term typically refers to, not as the barrier to safe harbor protection.

Correct Answer: Non-common space occupied and duration of occupation

OIG guidance requires the common space charge to be apportioned among all physicians and subtenants who use it, based on the amount of non-common space each occupies and the duration of that occupation. Option a is incorrect because a rental formula based on revenue attributable to services performed in the space is barred under the Stark rental compensation conditions, so it cannot set a share. Option b is incorrect because the guidance rejects a flat split; the building common space example states the supplier's share could not be split 50/50 among users. Option c is incorrect because patient volume is not an apportionment factor in the guidance, and tying rent to patient counts would invite the volume-based compensation problems the rules prohibit.

Correct Answer: Civil Monetary Penalties Law

The Civil Monetary Penalties Law, Section 1128A of the Social Security Act, authorizes HHS-OIG to impose civil penalties for violations of the Anti-Kickback Statute and other related violations. Option a is incorrect because it imposes liability on persons who knowingly submit or cause the submission of false or fraudulent claims, rather than addressing kickback violations through HHS-OIG penalties. Option c is incorrect because it prohibits a physician from referring Medicare and Medicaid beneficiaries to an entity with which the physician has a financial relationship, and does not grant HHS-OIG penalty authority. Option d is incorrect because they give HHS-OIG authority to bar individuals from participating in federal health care programs, which is a different remedy from imposing civil penalties.

Correct Answer: Specific intent to defraud

The statutory definition of "knowing" and "knowingly" covers actual knowledge, deliberate ignorance and reckless disregard, and states that no proof of specific intent to defraud is required for liability. Option a is incorrect because acting in deliberate ignorance is the second listed form of knowing conduct, which means it can establish liability instead of being excused from proof. Option b is incorrect because actual knowledge is the first of three listed ways a person can act knowingly, so it is a qualifying state of mind rather than an excluded one. Option c is incorrect because reckless disregard is the third listed form of knowing conduct and is expressly included in the definition, not removed from it.

Correct Answer: An HHS administrative law judge

CMP cases under the Civil Monetary Penalties Law are administrative. OIG pursues them before an HHS administrative law judge, unlike False Claims Act cases, which DOJ pursues in Federal court. Option b is incorrect because federal court is where DOJ pursues False Claims Act cases on behalf of HHS, not where administrative CMP cases are heard. Option c is incorrect because ONC issues regulations defining information blocking conduct; it does not hear cases or decide CMPs brought by OIG. Option d is incorrect because the statute mentions Supreme Court review only as a later step after court judgments, not as the forum where OIG brings CMP cases.

Correct Answer: I, II, and III

The False Claims Act anti-retaliation provision makes the employee whole through reinstatement with the same seniority status, 2 times back pay with interest, and compensation for special damages, including litigation costs and reasonable attorneys' fees. Option a is incorrect because it omits compensation for special damages, which the statute also lists, including litigation costs and reasonable attorneys' fees, so this combination is incomplete. Option c is incorrect because it leaves out reinstatement with seniority and adds a remedy the statute does not list, since relief is not limited to emotional distress damages. Option d is incorrect because it includes statement IV, but the statute names no separate relief of exemplary damages for emotional distress only; special damages are the listed category.

Correct Answer: Material to a false or fraudulent claim

The restated provision imposes liability on any person who knowingly makes, uses, or causes to be made or used a false record or statement material to a false or fraudulent claim, so materiality is the linking requirement. Option a is incorrect because a receipt-certifying document belongs to the provision covering persons authorized to make or deliver such receipts, which is a different liability category from false records or statements. Option b is incorrect because intent to defraud is written into the provision on certifying receipt of Government property, while the record-or-statement provision requires only that the person act knowingly. Option c is incorrect because possession, custody, or control of Government money or property is the basis of the separate provision on delivering less than all of it.

Correct Answer: It is covered because one purpose was inducing referrals

OIG guidance explains that the statute has been interpreted to cover any arrangement where one purpose of the remuneration is to induce referrals for items or services reimbursable by a Federal health care program. This is the one-purpose test. Option a is incorrect because the statute reaches an arrangement when one purpose is to induce referrals; lawful additional purposes do not remove it, and only exceptions and safe harbors give protection. Option b is incorrect because OIG guidance says the statute has been interpreted to cover any arrangement where one purpose of the remuneration is inducement, not just a sole purpose. Option d is incorrect because remuneration counts as anything of value regardless of the amount, so a minimum payment size is not a condition of coverage.

Correct Answer: II and IV

OIG states that arrangements outside a safe harbor are evaluated on the totality of facts and circumstances, including intent, and that evaluating whether an arrangement can be restructured to fit within a safe harbor is a step to reduce risk. Option b is incorrect because both statements are contradicted by OIG guidance: missing a safe harbor does not make an arrangement automatically illegal, and protection requires every condition to be met. Option c is incorrect because it includes statement I, but OIG says failure to meet a safe harbor does not render an arrangement automatically illegal. Option d is incorrect because it adds statement III, yet safe harbor protection ends if even one condition is unmet, so meeting most conditions gives no protection.

Correct Answer: Remuneration passes between the parties with no intervening persons or entities between them

Under 42 CFR 411.354, a direct financial relationship exists when remuneration passes between the referring physician (or immediate family member) and the entity furnishing DHS without any intervening persons or entities. Option a is incorrect because claim submission concerns whether billing and payment are permitted, while classification as direct depends on how remuneration moves between the physician and the entity. Option b is incorrect because the regulation describes a relationship with intermediaries as indirect, which exists only under separate stated conditions, not as a direct relationship. Option d is incorrect because that is the special rule for reconciling compensation, which governs when a claim may be billed, not how a relationship is classified.