AAPC-CPCO Certified Professional Compliance Officer - Set 5 - Part 3

Correct Answer: I and II

The CFR is the codification of general and permanent rules published in the Federal Register by executive departments and agencies. Each title is divided into chapters, which usually bear the name of the issuing agency. Option b is incorrect because statement III is wrong, since the CFR is organized in sections within parts and most citations are provided at the section level, not the part level. Option c is incorrect because statement IV reverses the hierarchy: titles are the broad divisions and are split into chapters, so chapters are not subdivided into titles. Option d is incorrect because both statements fail, because citations mostly point to sections and chapters sit below titles, while this pair also leaves out the two accurate statements.

Correct Answer: 5 U.S.C. 402, Inspector General Act

The Inspector General Act, 5 U.S.C. 402, states that an Office of Inspector General is established in each of the listed establishments. Its purpose is independent and objective audits and investigations of agency programs and operations. Option a is incorrect because it sets penalties for certain violations and is enforced by OIG, but it does not establish the Offices of Inspector General. Option b is incorrect because it is a fraud and abuse law that bars people and entities from federal health care programs, not a law that sets up offices. Option d is incorrect because it is one of the federal Medicare fraud and abuse laws, which address improper conduct in programs rather than creating oversight offices within agencies.

Correct Answer: Advisory Opinion Denials

OIG's enforcement action summaries are grouped into categories such as Criminal and Civil, State Enforcement Agencies, and Self-Disclosure Settlements. Advisory Opinion Denials is not one of them; advisory opinions are a separate OIG resource. Option a is incorrect because it is one of the listed website categories, covering matters resolved through OIG's self-disclosure processes. Option b is incorrect because OIG names this among its enforcement action categories, which track problems arising under existing Corporate Integrity Agreements. Option c is incorrect because this appears in OIG's list of categories, grouping penalty and exclusion actions together under one heading.

Correct Answer: It gives the group no legal protection or binding effect

Advisory opinions may legally be relied upon only by the requestors, and they bind the Secretary only as to the requesting party. Published opinions are informational, so no third party is bound by or may rely on them. Option a is incorrect because safe harbors come from separate regulations with preamble text, while an advisory opinion is a legal opinion on one requestor's specific certified facts. Option b is incorrect because the opinion binds the Secretary only with respect to the requesting party, so it creates no obligation toward other parties with comparable arrangements. Option d is incorrect because protection is tied to the facts certified by the requestor, and a similar arrangement of a non-requesting party does not receive that prospective protection.

Correct Answer: Joint Commission

The Joint Commission accredits health care organizations that meet quality and safety of care standards. Accreditation is one measure used to qualify facilities to participate in programs such as Medicare and Medicaid. Option a is incorrect because its focus is investigating organizations and individuals suspected of defrauding healthcare systems, which is an enforcement role and not accreditation. Option b is incorrect because it was created by CMS to collect data on the error rate for claims erroneously paid to providers, not to accredit organizations. Option c is incorrect because it sits within the Department of Health and Human Services and oversees HIPAA compliance, investigating and prosecuting violations rather than accrediting facilities.

Correct Answer: Centers for Medicare & Medicaid Services (CMS)

CMS is the federal agency within HHS that administers Medicare, Medicaid, SCHIP, CLIA, and other health-related programs. To protect program integrity, it works with partners such as OIG, the FBI, DOJ, and review contractors. Option b is incorrect because CMS lists it among the state and federal law enforcement agencies it partners with, so it supports program integrity rather than administering these programs. Option c is incorrect because it is a law enforcement partner that CMS works with to prevent and detect fraud and abuse, and it issues voluntary compliance program guidance. Option d is incorrect because it appears in CMS guidance as a law enforcement partner in fighting fraud and abuse, not as the administrator of Medicare, Medicaid, SCHIP, or CLIA.

Correct Answer: Children's Health Insurance Program Reauthorization Act

The Children's Health Insurance Program Reauthorization Act marked a new era in children's coverage by giving states significant new funding, new programmatic options, and incentives to cover children through Medicaid and the Children's Health Insurance Program. Option a is incorrect because its main features were barring denials or higher charges based on health status, expanding Medicaid, and subsidizing Marketplace insurance, not children-focused funding incentives. Option b is incorrect because it established Medicaid as a jointly funded federal and state program for people with low incomes; it is not later legislation aimed at children's coverage. Option c is incorrect because it created the Children's Health Insurance Program itself and revised Medicaid managed care and disproportionate share hospital rules, rather than adding new funding and incentives later.

Correct Answer: Third-Party Payer

A Third-Party Payer is an entity other than the patient or the health care provider that reimburses and manages healthcare expenses. The insurance company in the scenario fits that definition exactly. Option b is incorrect because this is an individual who ensures a company follows outside regulatory and legal requirements and internal policies, not an entity that reimburses expenses. Option c is incorrect because an accrediting body such as the Joint Commission judges whether organizations meet quality and safety standards; it does not pay or manage healthcare expenses. Option d is incorrect because agencies such as OCR or the FBI enforce rules and investigate wrongdoing, which differs from reimbursing and managing the cost of care.

Correct Answer: Consider avoiding the consulting relationship

When the physician's contribution is the ability to prescribe, use a device or refer, the arrangement could violate fraud and abuse laws, so the physician should consider avoiding the consulting relationship. Option a is incorrect because PhRMA and AdvaMed codes address relationships with health care professionals, yet the guidance still warns that paying for prescribing or use could violate fraud and abuse laws. Option b is incorrect because separate storage is advice about free product samples, which are a different subject from consulting or speaker arrangements with device companies. Option d is incorrect because fair market value protects a relationship only when the physician's contribution is time and effort, not the ability to use a device or refer.

Correct Answer: Nonmaleficence

Nonmaleficence is the provider's responsibility to do no harm to patients. Because many treatments carry risks, this principle requires that the benefits outweigh the risks of medical treatment. Option b is incorrect because it addresses fairness and equality and requires no discrimination in the delivery of healthcare services, so it does not govern risk-benefit balance. Option c is incorrect because it refers to the provider's responsibility to do what is in the best interest of others, not to weigh treatment risk against benefit. Option d is incorrect because it concerns autonomy, privacy, rights, and interests of patients, including informed decisions and consent, rather than the balance of treatment risks.