AAPC-CPMA Certified Professional Medical Auditor - Set 3 - Part 1

Correct Answer: It ends when the fixed period ends

The suspension for related overpayments lasts until the earlier of the concluded investigation with a calculated aggregate amount or the fixed number of days after identification. Because the fixed period has already ended, the suspension ends then. Option a is incorrect because the suspension runs only to the earlier of the two events, so an open investigation cannot extend it past the fixed period. Option b is incorrect because a settlement agreement under a disclosure protocol satisfies the reporting obligation, but it is not one of the two events that end this suspension. Option c is incorrect because cost report filing is the applicable reconciliation point for SSI ratio updates and outlier reconciliations, and it is not an end point for this suspension.

Correct Answer: Measuring Compliance Program Effectiveness toolkit

OIG published the toolkit Measuring Compliance Program Effectiveness, organized around the seven compliance program elements. Entities select evaluative tools from it to assess how effective each element is, though it is not a checklist for the whole program. Option b is incorrect because this COSO publication is named as a standard resource for building risk assessment methods, not for evaluating how effective each program element is. Option c is incorrect because the work plan schedules audits and monitoring of prioritized risks after a risk assessment; it does not evaluate each element's effectiveness. Option d is incorrect because this regulation is cited as a reason some functions, such as audit, may need extra risk assessments, and it is not an effectiveness review tool.

Correct Answer: Intent to defraud, proved beyond a reasonable doubt

For criminal penalties, the standard is higher than civil liability: the Government must prove intent to defraud beyond a reasonable doubt. Specific intent to violate the statute itself is not required for a conviction. Option a is incorrect because reckless disregard is a knowledge standard under the civil False Claims Act, whereas the criminal standard is described as even higher. Option b is incorrect because negligence and innocent errors fall outside civil, criminal and administrative penalties; they lead only to the return of the funds claimed in error. Option d is incorrect because this describes how the False Claims Act defines knowing, which does not require specific intent to defraud; criminal conviction demands intent to defraud.

Correct Answer: Mandatory exclusion from Federal health care programs

OIG guidance states that a violation of the Federal anti-kickback statute is a felony and that conviction leads to mandatory exclusion from Federal health care programs, including Medicare and Medicaid. Option b is incorrect because OIG may start administrative proceedings to exclude a person separately from a criminal case, but a conviction itself leads to mandatory exclusion. Option c is incorrect because safe harbor regulations list practices that are not treated as an offense, so they protect compliant arrangements rather than follow from a conviction. Option d is incorrect because liability under the statute is determined separately for each party involved, so the paying party can also be liable.

Correct Answer: Reduced repayment through the CMS SRDP

The CMS Voluntary Self-Referral Disclosure Protocol lets CMS reduce amounts owed for Physician Self-Referral Law violations, not Federal anti-kickback statute violations. The anti-kickback statute carries felony liability, mandatory exclusion on conviction, civil monetary penalties, and False Claims Act exposure. Option a is incorrect because conviction under the statute leads to mandatory exclusion from Federal health care programs, including Medicare and Medicaid, so it is a genuine consequence. Option b is incorrect because a person who commits an act described in section 1128B(b) of the Social Security Act may be subject to CMPs in addition to other liability. Option d is incorrect because the guidance states that a violation of the Federal anti-kickback statute constitutes a felony, with fines, imprisonment, or both as punishment.

Correct Answer: Beneficiary Inducements CMP

The Beneficiary Inducements CMP allows penalties against any person who offers or transfers remuneration to a Medicare or State health care program beneficiary when the person knows or should know it is likely to influence the beneficiary's selection of a particular provider. Option a is incorrect because it targets arranging with an individual or entity known to be excluded from Federal health care programs, a different problem from remuneration directed at beneficiaries. Option c is incorrect because it concerns failing to provide an adequate medical screening examination to hospital emergency department patients, which has no connection to gifts offered to beneficiaries. Option d is incorrect because it applies to grantees who knowingly use HHS grant funds for prohibited expenses, not to remuneration offered to beneficiaries to influence their choice of provider.

Correct Answer: They are summaries only and omit State fraud and abuse laws

OIG states the legal overviews are intended as summaries only. They do not address every legal obligation and specifically exclude State fraud and abuse laws, so following them does not establish full legal compliance. Option a is incorrect because the guidance expressly says it creates no new law or legal obligations, so the overviews cannot add duties beyond existing authorities. Option b is incorrect because the guidance says the discussions are not intended to be detailed or comprehensive, so following them cannot guarantee full legal compliance. Option c is incorrect because OIG guidance states that the overviews do not establish or interpret program rules or regulations; interpretation belongs to agencies such as DOJ, OIG, CMS and OCR.

Correct Answer: Medical direction or prescription of an excluded person

The effect of an OIG exclusion is that no Federal health care program payment may be made for items or services furnished by an excluded person or at the medical direction or on the prescription of an excluded person. Option b is incorrect because OIG guidance treats the payment as an overpayment regardless of whether the excluded person had such a number or could bill separately. Option c is incorrect because that presumption is a factor OIG weighs when deciding whether to impose exclusion for defrauding a program, not a rule that bars payment for items. Option d is incorrect because the pharmacy is not excluded, and the payment bar here attaches to the excluded prescriber's role rather than to any exclusion of the pharmacy.

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

Under 42 CFR 401.305, a person who has received an overpayment must report and return it by the later of 60 days after the date the overpayment was identified or the date any corresponding cost report is due, if applicable. Option a is incorrect because the regulation sets the deadline at the later of the two dates, so choosing the earlier date reverses the rule and shortens the time allowed. Option c is incorrect because that acknowledgment is an event that suspends the deadline until a settlement, withdrawal or removal; it does not set the deadline itself. Option d is incorrect because the 60-day clock starts when the overpayment was identified, not when payment was made, and the cost report date can extend it.

Correct Answer: Final reconciliation of that cost report

Under the applicable reconciliation provision, a provider that knows an outlier reconciliation will occur need not estimate the reimbursement change or return the estimated overpayment until the final reconciliation of that cost report. Option b is incorrect because disclosure protocol events are listed as separate circumstances affecting the deadline; the outlier provision does not tie the return of the estimated overpayment to them. Option c is incorrect because an extended repayment schedule request suspends the deadline until CMS or a contractor rejects it or terms are breached, which is a different rule. Option d is incorrect because that event ends a suspension of the deadline for related overpayments and has no connection to outlier reconciliation timing in a cost report.

Correct Answer: OIG acknowledging receipt of a submission to the OIG Self-Disclosure Protocol

The regulation suspends the deadline for returning overpayments when OIG acknowledges receipt of a submission to the OIG Self-Disclosure Protocol. The suspension remains until a settlement agreement is entered, the person withdraws, or the person is removed. Option a is incorrect because the 60-day period is the standard measure used to set the deadline itself, so reaching it ends the time allowed rather than suspending it. Option b is incorrect because this describes when an overpayment is identified, which starts the deadline period running; it does not pause the deadline once it is running. Option d is incorrect because the cost report due date is the alternative date in the deadline rule, applied as the later of two dates, and is not a suspension event.

Correct Answer: Overpayments and False Claims Act liability

OIG guidance links quality and patient safety concerns, including excessive services and medically unnecessary services, to overpayments and possible False Claims Act liability, which is why compliance programs should include quality oversight. Option a is incorrect because extrapolation requires a determination of sustained or high payment error, or failed educational intervention, not simply the presence of unnecessary services. Option c is incorrect because the LEIE is an exclusion list that entities screen monthly as routine monitoring; the guidance does not describe it as an automatic result of unnecessary services. Option d is incorrect because the work plan is an internal schedule of audits and monitoring built from risk assessment, and unnecessary services do not remove it.

Correct Answer: RACs and the SMRC

The Medicare program integrity instructions on statistical sampling apply to UPICs, RACs, the SMRC, and MACs, but RACs and the SMRC are specifically required to receive CMS COR approval through each step of the sampling process. Option a is incorrect because both are contractors the sampling section covers, but the step-by-step COR approval requirement is written specifically for RACs and the SMRC instead. Option b is incorrect because the SMRC is correctly paired, yet UPICs are listed only among contractors covered by the section, while RACs hold the other COR approval requirement. Option c is incorrect because RACs are named for COR approval, but MACs, including DME MACs, appear only as covered contractors; the SMRC is the second contractor named.

Correct Answer: Manner in which participants were selected

OIG's key questions place the inquiry into whether parties were selected because of past or anticipated referrals under the heading Manner in which participants were selected. The list is illustrative, and its answers alone are not determinative. Option a is incorrect because that category asks whether payment takes into account the volume or value of business generated, not why a party was chosen to participate. Option b is incorrect because that category concerns whether items and services are actually needed, rendered, commercially reasonable and necessary for a legitimate business purpose. Option d is incorrect because that category looks at fair market value, arm's-length terms and inflated or below-market rates, rather than how the parties were selected.

Correct Answer: Examining claims denial history for frequent error sources

OIG guidance says initial development can focus on problematic risk areas such as coding and billing. The practice should examine its claims denial history or repeated overpayments and correct the most frequent sources of those errors. Option a is incorrect because a sponsoring entity that reviews claims or oversees compliance without fair market value payment implicates the anti-kickback and Stark self-referral laws. Option b is incorrect because an Integrity Agreement is a settlement document that can serve as a resource for small providers, not a required starting point. Option c is incorrect because OIG describes implementation as multi-tiered, with early work aimed at problematic areas rather than completing every component first.

Correct Answer: I and II

OIG describes the GCPG as voluntary guidance that is not binding on any individual or entity. Its "should" language presents voluntary, nonbinding guidance, so only statements I and II are accurate. Option b is incorrect because statement III is false, since OIG uses "should" in the GCPG to present voluntary, nonbinding guidance rather than a requirement, and II is left out. Option c is incorrect because statement IV contradicts statement II; guidance that binds no individual or entity cannot demand full adoption as a condition of being compliant, and I is omitted. Option d is incorrect because both statements treat the GCPG as compulsory, while OIG describes it as a voluntary reference guide, and the two true statements are missing.

Correct Answer: Individuals responsible for conducting the screening

OIG guidance says the screening policy should clearly identify which individuals are responsible for conducting the screening, along with the screening and match-verification process and the steps to take when an excluded individual or entity is found. Option a is incorrect because meeting frequency is addressed in the guidance on the Compliance Committee, which should meet no less than quarterly, and not as a content item of the screening policy. Option b is incorrect because OIG points entities to its subsector Compliance Program Guidance for those risks; the screening policy is not described as the place to list them. Option c is incorrect because reporting to the board is a primary responsibility of the compliance officer, not a required element of the screening policy itself.

Correct Answer: The CEO or the board

OIG guidance states the compliance officer should report directly to the CEO or the board, and should not lead or report to the legal or financial functions, which protects the officer's independence. Option a is incorrect because general counsel usually leads the legal function, and OIG guidance says the compliance officer should not lead or report to that function. Option b is incorrect because the compliance officer chairs this committee rather than reporting to it, and the guidance names the CEO or board as the reporting line. Option d is incorrect because this leader heads the financial function, so a reporting line there would compromise the separation OIG guidance calls for.

Correct Answer: Providing another way to obtain the policies

OIG guidance says relevant individuals should be able to easily access the code, policies, and procedures. If the entity's communication method does not reach everyone, the entity should employ an alternative mechanism for access. Option b is incorrect because a scheduled review keeps policies in line with statutes and program requirements; it does nothing for people who cannot open the intranet site. Option c is incorrect because translation serves comprehensibility, helping readers understand the content, and does not solve the problem of individuals who cannot reach the policies at all. Option d is incorrect because that step concerns the timing of new or revised policies relative to implementation, so it leaves the access problem untouched.

Correct Answer: The compliance officer

OIG guidance under Element 3, Training and Education, states that the compliance officer, with the support and aid of the Compliance Committee, should develop and coordinate a multifaceted education and training program specific to the entity's needs and risks. Option a is incorrect because outside seminars are one training modality a practice may use, but the guidance does not give a seminar provider responsibility for developing the program. Option c is incorrect because the board's role in the guidance is oversight of the program and its risk assessment process, not developing or coordinating the training program. Option d is incorrect because a liaison is suggested to keep a strong tie between an outsourced compliance officer and daily operations, not to build the training program.