AAPC-CPCO Certified Professional Compliance Officer - Set 5 - Part 2

Correct Answer: Standards and procedures review

OIG guidance says ongoing evaluation covers whether the practice's standards and procedures are current and accurate. A standards and procedures review addresses that, while a claims submission audit addresses whether claims are submitted appropriately. Option a is incorrect because it is routine monitoring of a known risk, such as the LEIE and State Medicaid lists, not a review of written standards. Option b is incorrect because it examines denials and repeated overpayments to find their most frequent sources, and does not assess whether the practice's written policies are up to date. Option d is incorrect because it tests whether claims are submitted appropriately, which concerns billing output rather than whether the written standards and procedures are current and accurate.

Correct Answer: Include a schedule of audits in the compliance work plan

OIG guidance directs the Compliance Committee to put into the compliance work plan a schedule of audits based on risks identified by the annual risk assessment, so the ranked risks drive the audit schedule. Option b is incorrect because the guidance names internal or external auditors with expertise in Federal and State health care statutes, regulations and program requirements, not the staff who prepare the claims. Option c is incorrect because routine monitoring of ongoing risks is one part of the work plan, which also carries a schedule of audits built from the identified risks. Option d is incorrect because OIG guidance calls for periodic assessments conducted at least annually and says more frequent assessments need dedicated time and resources; it does not tie them to each audit.

Correct Answer: Determine the question case by case

OIG guidance states that whether a material violation of applicable law exists must be determined on a case-by-case basis, and a monetary loss to a Federal health care program is not solely determinative. Option a is incorrect because OIG guidance states that the existence or amount of a monetary loss is not solely determinative of whether a violation has occurred. Option c is incorrect because allegations of noncompliant conduct should be investigated, and the outcome of that investigation guides what reporting to the Government is needed. Option d is incorrect because the guidance expects the compliance officer to act promptly on reports or reasonable indications of noncompliance, not to wait for outside demands.

Correct Answer: Remove them from current work activity until completion

OIG guidance states that when counsel or the compliance officer believes investigation integrity may be at stake because of employees under investigation, those subjects should be removed from their current work activity until the investigation is completed, unless an undercover operation is in effect. Option a is incorrect because OIG guidance calls for a contemporaneous record kept during the investigation, so waiting until closure contradicts it and does nothing to address the employees' presence. Option b is incorrect because reporting comes after credible evidence is found and a reasonable inquiry is made, and it does not deal with subjects who threaten the investigation's integrity. Option c is incorrect because external counsel, auditors or experts may be engaged to aid the investigation, not to replace interviews, and engaging them leaves the subjects in place.

Correct Answer: The statistically valid sampling and extrapolation methodology

Under the reporting rule, a person who calculates an overpayment using a statistical sampling methodology must describe the statistically valid sampling and extrapolation methodology in the report made through the contractor's reporting process. Option a is incorrect because a settlement agreement is the outcome of a disclosure under the OIG or CMS protocols, which is a separate route that satisfies the reporting obligation. Option b is incorrect because the outlier provision addresses when an estimated overpayment is returned, so it is a timing rule and not the description required for a sampled calculation. Option d is incorrect because the reconciliation date concerns when certain overpayments must be returned, and the reporting rule does not make it the item a sampling report must describe.

Correct Answer: The reason for the overpayment

The statute requires a person who returns an overpayment to notify the Secretary, State, intermediary, carrier, or contractor in writing of the reason for the overpayment. This notice is a duty separate from reporting and returning. Option a is incorrect because the correct address is where the report and return go, which is a separate duty from the written notice. Option c is incorrect because identification starts the 60-day period for the deadline, but the statute does not name it as what the written notice must explain. Option d is incorrect because a cost report due date is one possible point for measuring the deadline; the statute does not make it the content of the written notice.

Correct Answer: Disclosure made in good faith

OIG guidance states that disclosing parties already subject to a Government inquiry are not automatically precluded from the SDP, but the disclosure must be made in good faith and must not be an attempt to circumvent the inquiry. Option a is incorrect because a party cannot step out of an inquiry to qualify; the guidance simply bars using the SDP as an attempt to circumvent it. Option b is incorrect because OIG guidance does not require approval from the agency conducting the inquiry; it says only that such parties are not automatically precluded from using the SDP. Option c is incorrect because nothing in the SDP guidance makes the end of an audit or investigation a prerequisite, since parties under inquiry may still disclose.

Correct Answer: A lower multiplier on single damages

OIG states that persons who use the SDP and cooperate deserve to pay a lower multiplier on single damages than would normally be required when resolving a Government-initiated investigation. The specific multiplier may vary with the facts. Option b is incorrect because the statute sets the 60-day deadline for reporting and returning overpayments; the SDP may only mitigate exposure under it and does not lengthen it. Option c is incorrect because OIG instituted a presumption against requiring integrity agreement obligations in SDP resolutions, so this would be a burden, not a benefit. Option d is incorrect because the SDP cannot be used to request an opinion; the Advisory Opinion process is the vehicle for obtaining an OIG opinion.

Correct Answer: Sources of Data

The Sources of Data element of the review report calls for a full description of the data reviewed and the information the review was based on, including the sources of payment data and the documents relied upon. Option a is incorrect because the sampling frame belongs to the sampling plan and covers the totality of sampling units from which the sample was selected, not the documents relied upon. Option b is incorrect because this element identifies the characteristics used to test each item and the method for judging whether an item meets the criterion, not where the data came from. Option d is incorrect because the Population element describes the group of claims at issue and the methodology and basis used to develop that group, not the data sources.

Correct Answer: It does not necessarily mean OIG found the person low risk

OIG reserves its exclusion authorities for one of several reasons: closing its case, considering unilateral monitoring, or considering exclusion. Reservation does not necessarily mean OIG concluded the person poses a low risk, and a person may ask OIG beforehand. Option a is incorrect because integrity obligations are a separate resolution OIG obtains in exchange for a release, whereas a reservation keeps the exclusion authorities intact without requiring a CIA. Option b is incorrect because OIG reserves its authorities for several reasons, including closing its case, so a reservation alone does not establish a higher-risk finding. Option c is incorrect because exclusion is only one of the reasons for a reservation; OIG may instead be closing its case or considering unilateral monitoring.

Correct Answer: Sampling Frame

The Sampling Frame is the totality of sampling units from which the sample was selected. It also requires the report to state how the audit population differs from the frame and what effect that difference has on conclusions. Option b is incorrect because the sampling unit is any designated element that makes up the population of interest, not the full set of units from which the sample came. Option c is incorrect because sample design addresses the selection approach, with simple random sampling expected unless a different design is justified, and it does not address population differences. Option d is incorrect because this element records how the sample units were chosen and says nothing about how the audit population departs from the pool sampled.

Correct Answer: A health oversight agency

Under the HIPAA whistleblower provision, a workforce member who believes in good faith that the covered entity acts unlawfully may disclose protected health information to a health oversight agency authorized by law to oversee that conduct. Option a is incorrect because the whistleblower provision lists oversight agencies, public health authorities, accreditation organizations and the workforce member's own attorney; media outlets are not among the permitted recipients. Option b is incorrect because a competitor has no authority to investigate or oversee the covered entity's conduct, so a disclosure there falls outside the safe harbor. Option d is incorrect because a payer marketing unit is not an oversight body or accreditation organization named in the provision, so disclosure to it is not protected.

Correct Answer: Inspector General and Attorney General

The statute gives the Inspector General of the Department of Health and Human Services and the Attorney General access to claims and payment data of the Department and its contractors, consistent with HIPAA and privacy laws. Option a is incorrect because these officials are named for data sharing and matching agreements with the Secretary, aimed at identifying potential fraud, waste, and abuse, not for direct database access. Option b is incorrect because the statute places them among those entering matching agreements; direct access to claims and payment data is given to different officials. Option c is incorrect because both appear on the list of individuals who share and match data from their own agencies' systems of records with the Department.

Correct Answer: The statutory authority for the subpoena

Under 45 CFR 160.314(a)(1), a subpoena the Secretary issues during an investigation or compliance review must state the name of the addressee, the statutory authority for the subpoena, the testimony date, time and place, and a description of required documents. Option a is incorrect because mitigating factors are evidence an entity may submit within a set period after informal resolution fails; they are not content of the subpoena. Option b is incorrect because a penalty finding comes later, in a notice of proposed determination, and is separate from the subpoena's required contents. Option d is incorrect because probable cause is the standard a magistrate judge applies when issuing a search warrant, and the HIPAA subpoena provisions do not list it as a required element.

Correct Answer: I, III, and IV

When the Government proceeds, it has primary responsibility for prosecuting the action and is not bound by the other person's acts. That person may continue as a party, and the Government may dismiss after notice and a hearing opportunity. Option a is incorrect because it leaves out statement IV, which is also accurate: the statute lets the Government dismiss despite objections once notice and a hearing opportunity are given. Option c is incorrect because it relies on statement II, which reverses the statute, and it omits the Government's primary prosecutorial responsibility and its dismissal authority. Option d is incorrect because statement II is false, since the statute says the Government is not bound by the acts of the person bringing the action; it also drops III.

Correct Answer: CMS Self-Referral Disclosure Protocol

The SDP is unavailable for arrangements with only Stark law liability and no accompanying AKS liability. Such Stark-only conduct should be disclosed to CMS through its Self-Referral Disclosure Protocol. Option b is incorrect because the hotline is meant for reporting potential misconduct of other, unrelated parties, not for a party's own self-referral liability. Option c is incorrect because the Advisory Opinion process is the vehicle for obtaining an OIG opinion on an arrangement, not a channel for disclosing Stark-only conduct. Option d is incorrect because that route handles matters exclusively involving overpayments or errors, which do not involve potential violations carrying CMP authority.

Correct Answer: Reportable event

Under a CIA, a provider must report to OIG within 30 days all reportable events as the CIA defines them. Employing or contracting with an ineligible person is one of the listed categories. Option a is incorrect because it sits at the lower-risk end of the spectrum alongside release and describes a way of resolving a matter, not notice about an ineligible contractor. Option b is incorrect because it marks a position on OIG's risk spectrum, between exclusion and integrity obligations, and does not name an occurrence a provider must notify OIG about. Option d is incorrect because it describes OIG using Inspector General Act authorities to watch a person who refused integrity obligations, which is an OIG action rather than a provider occurrence.

Correct Answer: The provider determines the most appropriate IRO to engage

OIG guidance states that it is up to the provider to determine the most appropriate accounting firm, law firm, or consultant to engage as its IRO. OIG neither endorses nor assists in the choice. Option a is incorrect because the guidance gives the choice to the provider, and a payer has no stated role in choosing the organization that performs the review. Option c is incorrect because OIG states it will not indicate which IROs it believes are most qualified, so it gives no such endorsement to a provider. Option d is incorrect because OIG does not maintain a list of recommended or approved IROs, so it has no list from which to assign one.

Correct Answer: Administrative and management services remain barred

OIG guidance states that excluded persons may not furnish administrative and management services payable by Federal health care programs, even if not separately billable. A physician practice office manager is listed as a barred role. Option b is incorrect because the prohibition applies even when services are not separately billable or are included in a bundled payment, so billing status does not decide coverage. Option c is incorrect because the regulation applies regardless of whether a provider number was obtained earlier; only reinstatement lifts the payment bar, not a number. Option d is incorrect because the OIG bulletin extends the payment prohibition beyond direct patient care, and names the physician practice office manager among barred leadership roles.

Correct Answer: The Secretary's waiver decision is open to review

The Exclusion Statute states that the Secretary's decision whether to waive the exclusion shall not be reviewable. A waiver decision therefore cannot be challenged through review, which makes this option the one that is not part of the process. Option a is incorrect because the statute directs the Secretary to consult with the Inspector General of the Department of Health and Human Services before granting a waiver, so it is a genuine step. Option b is incorrect because the statute limits the waiver to an individual or entity in that sole-provider position in a community, so this is a real condition. Option c is incorrect because the statute makes the request of a program administrator, who determines the exclusion would impose a hardship on beneficiaries, the starting point for any waiver.