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

Correct Answer: It still needs separate analysis under the Federal anti-kickback statute

The regulation states that Stark provides no exceptions or immunity from sanctions under State laws or Federal law other than section 1877. The Stark law and the Federal anti-kickback statute are separate laws needing separate evaluations. Option b is incorrect because meeting a Stark exception is a Stark finding only; the regulation grants no immunity under other Federal law, and the False Claims Act is such a law. Option c is incorrect because the regulation states that the subpart gives no immunity from civil or criminal prosecution or other sanctions under any State laws, so State exposure remains. Option d is incorrect because the regulation says the subpart provides no exceptions or immunity from sanctions under Federal law other than section 1877, so the anti-kickback statute still applies.

Correct Answer: Ownership, investment, or compensation arrangements

The Stark subpart requires, with some exceptions, that certain entities furnishing covered services under Medicare report information concerning ownership, investment, or compensation arrangements, in the form, manner, and times CMS specifies. Option a is incorrect because it is a separate set of rules that the Stark subpart leaves unchanged; it is not the information the reporting requirement covers. Option b is incorrect because payment for incident-to services and supplies is governed by a different Medicare provision, not by the reporting requirement in the Stark subpart. Option d is incorrect because purchased diagnostic tests fall under their own payment rules, which the subpart expressly does not alter, so they are not the reportable subject.

Correct Answer: A beneficiary

The Civil Monetary Penalties Law applies to any person, including an organization, agency, or other entity, but it expressly excludes a beneficiary. A beneficiary therefore cannot be penalized under the improperly filed claims provision. Option a is incorrect because the statute expressly lists an organization among those included in the term person, so an organization can be penalized for improperly filed claims. Option b is incorrect because the statute names an agency as one kind of person that is covered, so it is not carved out of the penalty provision. Option c is incorrect because the statute extends the term person to other entities as well, which makes them subject to the penalties instead of exempt from them.

Correct Answer: Remuneration

For the Beneficiary Inducements CMP, "remuneration" is defined to include transfers of items or services for free or for other than fair market value, along with waivers of coinsurance and deductible amounts. Option b is incorrect because nominal value is the threshold OIG applies to exclude inexpensive items from the prohibition, not the label for the transfer. Option c is incorrect because inducement is a separate element of the prohibition, describing the effect the offer is meant to have on the beneficiary, not the transferred item or service. Option d is incorrect because preventive care is the subject of one exception, covering incentives to promote delivery of covered services, and does not name the transfer itself.

Correct Answer: Sworn statement of the person furnishing the items

The regulation allows payment for certain emergency items or services only when the claim is accompanied by a sworn statement of the person furnishing them, specifying the nature of the emergency and why an eligible individual or entity could not have furnished them. Option a is incorrect because the regulation requires a sworn statement describing the nature of the emergency and why an eligible individual could not furnish the items, not a certification of necessity. Option b is incorrect because the regulation names a sworn statement from the person furnishing the items or services as the accompanying document and does not mention any employer waiver. Option d is incorrect because the mailed notice of exclusion only starts the 15-day period for claims payment; it is not the document that makes an emergency claim payable.

Correct Answer: Delivery of or payment for health care benefits, items, or services

The criminal health care fraud statute covers a scheme to defraud a health care benefit program or obtain its money or property, executed in connection with the delivery of or payment for health care benefits, items, or services. Option b is incorrect because that wording belongs to the Social Security Act false statement offense on applications for benefits, not to the connection element of the fraud statute. Option c is incorrect because inducing referrals describes a kickback offense, a separate Social Security Act crime, and is not what ties a scheme to the fraud statute. Option d is incorrect because the statute reaches schemes against any health care benefit program, so enrollment as a provider in a Federal program is not the required link.

Correct Answer: Permissive exclusion for false statements or misrepresentation of material facts

PPACA added a permissive exclusion for any individual or entity that knowingly makes or causes to be made a false statement, omission, or misrepresentation of a material fact in an application to enroll under a Federal health care program. Option a is incorrect because it requires Medicare to give States identifying information on terminated providers within a set period, rather than creating an exclusion basis for misrepresentation. Option c is incorrect because it applies to States that fail to report enrollee encounter data on time, not to providers who misstate facts in applications. Option d is incorrect because it is a screening-related fee imposed on institutional providers, and it does not penalize or exclude anyone for omissions in an application.

Correct Answer: An obligation under the False Claims Act

Under the PPACA overpayment provision, an overpayment kept after the 60-day or cost report deadline for reporting and returning is an obligation for purposes of the False Claims Act, creating potential liability. Option a is incorrect because permissive exclusion is a separate PPACA provision aimed at knowingly false statements or misrepresentations in enrollment applications, not at overpayments retained after the deadline. Option b is incorrect because withholding of federal matching payments is aimed at States that fail to report enrollee encounter data, so it does not reach a provider's retained overpayment. Option c is incorrect because that remedy applies to an applicable individual who knowingly joins a health care fraud scheme, and a provider of services is not that individual.

Correct Answer: It constitutes a false or fraudulent claim

The PPACA added a subsection to the anti-kickback statute providing that a claim including items or services resulting from a violation constitutes a false or fraudulent claim for purposes of the False Claims Act provisions, in addition to existing penalties. Option a is incorrect because the data collection program covers reporting of final adverse actions against providers, suppliers or practitioners, and has no role in how a kickback-tainted claim is classified. Option b is incorrect because testimonial subpoena authority was added for exclusion-only investigations under a different section, and it does not define the status of a kickback-tainted claim. Option d is incorrect because the amendment states a person need not have actual knowledge of the statute or specific intent to commit a violation.

Correct Answer: An individual with direct and independent knowledge who voluntarily gave the information to the Government before filing

The former provision defined original source as an individual with direct and independent knowledge of the information behind the allegations who voluntarily provided it to the Government before filing. PPACA struck this paragraph and added a new one. Option a is incorrect because the news media was listed as one of the public-disclosure channels that triggered the bar, so using it did not make anyone an original source. Option c is incorrect because the definition required voluntary provision to the Government before the action was filed; supplying it afterward missed that timing element. Option d is incorrect because allegations drawn from a Government audit or investigation fell within the listed public disclosures, and the definition asked for the person's own knowledge, not reports.