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

Correct Answer: Presence during the key portion

OIG guidance for hospitals states that every physician should document his or her presence during the key portion of any service or procedure for which payment is sought, consistent with billing only for services actually provided. Option a is incorrect because resident training is not a documentation element named for teaching physician claims; the guidance requires documenting the physician's own presence instead. Option b is incorrect because direct supervision of auxiliary personnel is a condition for incident to services in a noninstitutional setting, not the teaching physician documentation item. Option c is incorrect because the guidance does not tie teaching physician documentation to total time; it focuses on presence during the key portion of the service.

Correct Answer: The later of 60 days after identification or the cost report due date

The statute requires an overpayment to be reported and returned by the later of 60 days after the date it was identified or the date any corresponding cost report is due, if applicable. Option a is incorrect because the 60-day period runs from the date the overpayment was identified, not from claim submission, so this starting point is wrong. Option b is incorrect because the statute ties the deadline to identification of the overpayment and any cost report due date, and gives payer audit notices no role. Option d is incorrect because the statute sets the deadline at the later of the two dates, not the earlier, whenever a corresponding cost report applies.

Correct Answer: A valid written notice was given and the beneficiary consented to the service

When a beneficiary received a valid written notice such as an ABN and consented to the service, knowledge exists and payment responsibility rests with the beneficiary, not the provider or supplier. The other situations shift liability to the provider or supplier. Option b is incorrect because the contractor makes an immediate finding of liability when services are patently unnecessary and every provider could reasonably be expected to know they are not covered. Option c is incorrect because the guidance states that a formal finding of fraud or abuse produces an immediate finding of liability for the provider or supplier, so it is a liability circumstance. Option d is incorrect because the contractor overrides the GA indicator when the notice proves invalid, and the provider or supplier is then found liable for the denied charges.

Correct Answer: I, II, and IV

The regulation says the physician decides admissions and length of stay, and certification of necessity is a condition for Medicare payment. OIG guidance adds that knowing falsity risks criminal, civil and administrative liability, while simple negligence does not. Option a is incorrect because it leaves out statement IV, which OIG guidance supports because knowing falsity in a signed certification exposes the physician to criminal, civil and administrative liability. Option c is incorrect because it includes statement III, but OIG guidance says a signature made through mistake, simple negligence or inadvertence does not create personal liability, and it omits I. Option d is incorrect because it adds statement III, which conflicts with OIG guidance on negligence, and drops statement II, although certification is expressly a condition for Medicare payment.

Correct Answer: Payment denied as not reasonable and necessary

Under the physician refund requirement, a nonparticipating physician who does not accept assignment must refund amounts collected for physicians' services denied as not reasonable and necessary under the statute. This includes a reduced level of payment. Option a is incorrect because supplier number requirements apply to medical equipment and supplies suppliers under the separate refund provisions, not to the physician services refund provision for nonassigned claims. Option b is incorrect because a claim for payment after the beneficiary's death is one of the listed conditions that takes the physician outside the refund provision. Option d is incorrect because the prohibition on unsolicited telephone contacts is a ground for denial of medical equipment and supplies claims, so it does not trigger the physician services refund.

Correct Answer: Nonparticipating physician not accepting assignment

The statute applies the limiting charge rules to a nonparticipating physician, supplier or other person who does not accept payment on an assignment-related basis for a service furnished to an enrolled individual. Option a is incorrect because this physician is nonparticipating, but the same condition also requires that assignment-related payment is not accepted, and accepting it removes the physician from the stated scope. Option b is incorrect because the provision applies to a person who does not accept payment on an assignment-related basis, so a physician who accepts assignment falls outside its stated condition. Option c is incorrect because the rules are tied to a service furnished to an individual enrolled under this part, a condition this situation lacks.

Correct Answer: Penalties under the anti-kickback statute

Compensation for a signature, including cash, free goods, or any other thing of value, may trigger additional criminal and civil penalties under the anti-kickback statute, beyond the risk from signing certifications without verifying need. Option a is incorrect because that duty falls on the provider, who must obtain the statements, keep them on file for verification, and certify on the billing form. Option c is incorrect because recertification is a payment condition requiring the physician to confirm continued need for services, and it carries no penalty tied to receiving items of value. Option d is incorrect because OIG guidance says a signature given through mistake, simple negligence, or inadvertence does not result in personal liability, and that is not the exposure created by compensation.

Correct Answer: Gift exchanges may be viewed as inducements to influence business decisions

OIG guidance lists gifts of more than nominal value to or from those who may benefit from referrals as a risk factor, and says clear standards are needed because such exchanges may be viewed as inducements to influence business decisions. Option a is incorrect because safe harbors protect an arrangement only when their specific conditions are fully met, and the guidance does not grant that protection to gifts automatically. Option b is incorrect because the guidance states there is no requirement that a practice retain its compliance records, so record retention is not the reason for gift standards. Option d is incorrect because free samples are drug or biologic products that may be given to patients at no charge, which is a separate topic from gifts exchanged with referral sources.

Correct Answer: Genuine financial hardship of a particular patient

OIG guidance permits forgiving a copayment only in consideration of a particular patient's genuine financial hardship. It must be occasional rather than routine, and otherwise a good faith effort to collect deductibles and copayments is required. Option a is incorrect because the hardship exception must not be used routinely, and a blanket policy is exactly the routine waiver that the guidance identifies as improper. Option b is incorrect because patient preference is not an exception; the guidance notes that patients who pay some portion choose services for medical need rather than because they are free. Option c is incorrect because forgiving obligations to generate business is the kind of inducement the anti-kickback statute makes illegal, so it cannot justify a waiver.

Correct Answer: Service and activity logs

OIG guidance on financial arrangements tracking says systems should account for service and activity logs, and for use of lease space and equipment, as applicable, to ensure consistency with contract terms. Option a is incorrect because joint ventures are a topic of the OIG Special Fraud Alerts, but the tracking guidance does not name investor lists as a monitoring item. Option c is incorrect because drug marketing practices are a past Special Fraud Alert topic area, not an item the tracking guidance lists for contract consistency. Option d is incorrect because disclosure policies come from grant funders and FDA and address conflicts of interest, while the tracking guidance points to logs and lease or equipment use.