AAPC-CPMA Certified Professional Medical Auditor - Set 2 - Part 2

Correct Answer: Assessments in lieu of damages, CMPs, and exclusion

OIG guidance states that under the Civil Monetary Penalties Law, OIG can pursue assessments in lieu of damages, CMPs, and exclusion from participation in the Federal health care programs. These cases are administrative, heard before an HHS administrative law judge. Option a is incorrect because the 60-day repayment duty comes from the Affordable Care Act overpayment requirement, not from the CMPL, which lists assessments, CMPs and exclusion as OIG remedies. Option b is incorrect because criminal penalties are named among possible consequences of violating fraud and abuse laws generally, but they are not listed among the remedies OIG pursues under the CMPL. Option d is incorrect because False Claims Act cases are pursued by DOJ on behalf of HHS in Federal court, while CMP cases are administrative and handled by OIG.

Correct Answer: It includes transfers of items or services for free

The Beneficiary Inducements CMP defines remuneration as including transfers of items or services for free or for other than fair market value. This definition is separate from the one used for the Federal anti-kickback statute. Option a is incorrect because OIG guidance states the Beneficiary Inducements CMP uses its own definition of remuneration, which does not apply for purposes of the Federal anti-kickback statute. Option c is incorrect because the CMP carries exceptions such as preventive care incentives and retailer rewards, and each condition of an exception must be squarely satisfied. Option d is incorrect because the definition expressly reaches transfers of items or services for other than fair market value, so below-value transfers fall within it rather than outside it.

Correct Answer: An overpayment

Payment for claims submitted to a Federal health care program for items or services furnished by an excluded individual or entity results in an overpayment, regardless of whether the excluded individual had a provider identification number or could bill separately. Option a is incorrect because a CMP is a sanction OIG may impose on those who arrange or contract with an excluded person, not the classification of the payment itself. Option b is incorrect because the effect of an OIG exclusion is that no Federal health care program payment may be made for such items or services. Option c is incorrect because a permissive exclusion is a discretionary OIG action against an individual or entity based on listed grounds, not a label for a payment.

Correct Answer: When a cost report is filed

The regulation states that the applicable reconciliation occurs when a cost report is filed. Final reconciliation of that cost report then governs when certain overpayments, such as those from updated SSI ratio information, must be returned. Option a is incorrect because concluding the investigation of related overpayments ends one suspension of the deadline, which is a separate matter from reconciliation. Option b is incorrect because identification of an overpayment starts the reporting and returning deadline, but the regulation does not tie applicable reconciliation to that event. Option d is incorrect because such a request only suspends the deadline for reporting and returning overpayments; it does not define when applicable reconciliation occurs.

Correct Answer: An appropriately credentialed clinician

Because Medicare requires items and services to be medically reasonable and necessary as a condition of payment, OIG guidance says claims reviews and audits should include medical necessity review by an appropriately credentialed clinician. Option a is incorrect because this body builds the compliance work plan and schedules audits from the annual risk assessment; it is not named as the reviewer of medical necessity. Option c is incorrect because compliance auditors may report to the compliance officer and conduct compliance audits, but the guidance assigns the medical necessity review itself to a credentialed clinician. Option d is incorrect because expertise in health care statutes and program requirements qualifies auditors to conduct audits, but it does not supply the clinical judgment needed for medical necessity.

Correct Answer: Knowing receipt or retention of the overpayment

Under 42 CFR 401.305, a person has identified an overpayment when the person knowingly receives or retains it. "Knowingly" carries the False Claims Act meaning given in 31 U.S.C. 3729(b)(1)(A). Option a is incorrect because the 60-day period is measured from the date the overpayment was identified, so it begins after identification and cannot be what establishes it. Option b is incorrect because an acknowledged OIG or CMS self-disclosure submission suspends the return deadline; it does nothing to determine when an overpayment counts as identified. Option d is incorrect because a corresponding cost report matters only as an alternative due date for reporting and returning, where applicable, rather than as the trigger for identification.

Correct Answer: Implementing all seven elements

OIG's longstanding belief is that an entity's leadership should commit to implementing all seven elements to achieve a successful compliance program. The guidance is meant to help entities fulfill that commitment in a robust and meaningful way. Option a is incorrect because OIG's stated belief is that leadership commits to the full set of seven elements, so a partial group of three falls short of that commitment. Option b is incorrect because OIG's experience monitoring Corporate Integrity Agreements informed its guidance, but that experience is a source of the guidance, not what leadership is asked to commit to. Option c is incorrect because written policies and procedures are only the first of the seven listed elements, and OIG expects leadership to commit to the rest as well.

Correct Answer: Return the funds claimed in error

OIG guidance states that when honest mistakes or negligence produce erroneous claims, the practice should return the funds erroneously claimed, without penalties. Absent a violation of law, erroneous claims result only in repayment. Option b is incorrect because the False Claims Act covers only actual knowledge, reckless disregard or deliberate ignorance of falsity, and does not reach mistakes, errors or negligence. Option c is incorrect because criminal penalties demand an even higher standard, proof of criminal intent to defraud beyond a reasonable doubt, which an honest mistake cannot meet. Option d is incorrect because this administrative remedy applies the same standard of proof as the False Claims Act, so an innocent error does not trigger it.

Correct Answer: To aid and support the compliance officer in implementing, operating, and monitoring the program

OIG guidance states that the Compliance Committee's purpose is to aid and support the compliance officer in implementing, operating, and monitoring the Compliance Program. The officer leads the program, and the committee assists. Option a is incorrect because reporting to the CEO with access to the board, or to the board directly, is the compliance officer's reporting line, not a committee purpose. Option b is incorrect because the guidance gives interview authority to the compliance officer, who may also designate an appropriate person, so the committee has no such duty. Option d is incorrect because the guidance designates a compliance officer as the leader of the program, and the committee's role is to support that officer rather than replace one.

Correct Answer: Handbook expanding upon the code of conduct

OIG guidance states that the code of conduct may not need regular review by design, but any handbook delineating or expanding upon the code should be regularly updated as statutes, regulations, and Federal health care program requirements change. Option a is incorrect because the endorsement is a written statement demonstrating broader organizational commitment to compliance; OIG guidance ties regular updating to handbooks, not to this statement. Option b is incorrect because this is a signed statement showing the CEO embraces the organization's commitment to compliance, not a document that must change with each shift in requirements. Option c is incorrect because OIG guidance says the code, by its design, may not need regular review, so it is the document that does not require routine revision.

Correct Answer: Determining when and how often education is needed

OIG guidance for physician practices lists three basic steps for setting educational objectives: who needs training, the type of training, and when and how often education is needed, including how much each person should receive. Option b is incorrect because outsourced compliance officers are discussed as a oversight option with limitations, not as one of the three basic steps for setting educational objectives. Option c is incorrect because anonymous reporting belongs to Element 4, lines of communication and disclosure programs, and is not among the three educational objective steps. Option d is incorrect because this is a suggested duty for the person overseeing compliance, covering employees and contractors, rather than a step in setting educational objectives.

Correct Answer: Education provided throughout the year

OIG guidance states education should not be limited to annual formal training, and the compliance officer should develop opportunities to educate on compliance topics and risks throughout the year, such as standing agenda items and video clips. Option a is incorrect because that concept ties participation in required training to continued employment or engagement, which concerns enforcement, not the ongoing education activities the policy lists. Option b is incorrect because language availability serves a culturally diverse audience; the policy says nothing about audience needs, only about when and how often education is delivered. Option c is incorrect because a waiver lets contracting entities' employees skip training by showing their own program meets requirements; the policy describes no contractor process.

Correct Answer: compliance officer

OIG guidance lists specific training topics, including the importance of open communication with the compliance officer and the various ways individuals can raise compliance questions and concerns with the compliance officer. Option a is incorrect because the committee supports and aids the compliance officer and reviews the training plan at least annually, but the training names the officer as the contact for concerns. Option c is incorrect because the guidance says a practice may work with such a company so documentation supports accurate claims, which concerns claim submission rather than receiving concerns. Option d is incorrect because a licensing board governs licensed personnel and sets the education they must complete; it is not where staff raise compliance concerns.

Correct Answer: The compliance officer can perform or oversee additional audits

OIG guidance says the Compliance Committee should ensure the compliance officer has the capacity to perform or oversee additional audits based on risks identified throughout the year, such as a systemic issue found in an overpayment investigation. Option a is incorrect because audits may be conducted by internal or external auditors with the right expertise, so the guidance does not hand every audit to outside reviewers. Option b is incorrect because routine monitoring covers ongoing known risks alongside audits, such as exclusion list screening, and is not a substitute for them. Option c is incorrect because OIG guidance sets the risk assessment at least annually and does not tie a repeat to each finding; it calls for added audit capacity instead.

Correct Answer: Claims review

The subject matter of IRO reviews under a CIA varies with the underlying conduct that led to the settlement. A case involving fraudulent billing would have a claims review. Option b is incorrect because OIG guidance links this review to cases involving a Federal anti-kickback statute or PSL violation, not to fraudulent billing. Option c is incorrect because OIG guidance ties an independent monitor with clinical expertise to quality-of-care issues, where delivery of care is examined rather than claims. Option d is incorrect because this requirement is typical of CIAs for pharmaceutical and device manufacturers monitoring sales force activities, and it does not address billing conduct.

Correct Answer: They must not reduce the estimate through netting

The Self-Disclosure Protocol states that the damages estimation must not include a reduction, or "netting," for underpayments found in the review, because a disclosing party may not extend the time to resubmit claims through the protocol. Option a is incorrect because the guidance says a disclosing party may not extend the time to resubmit claims through the protocol, which is the reason netting is barred. Option b is incorrect because verification is OIG's check of the disclosing party's damages calculation; the guidance gives it no role in allowing underpayments to reduce the estimate. Option c is incorrect because the Self-Disclosure Protocol bars any reduction, or netting, for underpayments, so an offset against the improper amounts would understate damages.

Correct Answer: Remove the subjects from their current work activity

OIG guidance states that when counsel or the compliance officer believes the integrity of the investigation may be at stake because of employees under investigation, those subjects should be removed from their current work activity until the investigation is completed. Option a is incorrect because sharing findings with the people under investigation would work against protecting integrity; the guidance instead stresses securing evidence and separating subjects from their work. Option b is incorrect because the guidance calls for removal from current work activity until the investigation is completed, not termination, which belongs to disciplinary action taken after the findings. Option d is incorrect because engaging external counsel, auditors, or experts is something entities consider based on scope and severity; it does not pause the investigation.

Correct Answer: Determining the root cause of the conduct

Under Element 7, the compliance officer should gather information throughout an investigation and work with appropriate individuals to determine the root cause of the conduct, so the entity can make the changes needed to prevent a recurrence. Option b is incorrect because retaining an outside expert is something the board may consider when directing a compliance program effectiveness review, not a task assigned to the compliance officer here. Option c is incorrect because the Compliance Committee has a defined role in ensuring the entity takes steps to prevent recurrence and strengthen vulnerable areas, so removing it contradicts the guidance. Option d is incorrect because the guidance expects work to continue beyond immediate fixes, because recurrence can be prevented only once the underlying cause is identified and addressed.

Correct Answer: The Compliance Committee

OIG guidance states that the Compliance Committee should be responsible for conducting and implementing the compliance risk assessment, then work with the compliance officer to prioritize resources and develop the compliance work plan. Option a is incorrect because the board's role in this guidance is to direct the compliance program effectiveness review and receive its findings, not to carry out the risk assessment. Option c is incorrect because a billing contractor is described only as a third party through which an entity may access its data, not as the owner of the assessment. Option d is incorrect because an outside expert is mentioned only as an option the board may retain for the effectiveness review, depending on resources and compliance history.

Correct Answer: I and II

The anti-kickback statute imposes criminal penalties for knowingly offering, paying, soliciting or receiving remuneration to induce federal program business, and remuneration for referrals is illegal because it can distort medical decision-making. Statements I and II are accurate. Option b is incorrect because statement III is false, since the statute also reaches those who knowingly offer or pay remuneration, not just the party receiving it. Option c is incorrect because statement IV misstates OIG guidance, which advises standards encouraging compliance with both the anti-kickback statute and the physician self-referral law, and this pair drops true statement I. Option d is incorrect because both statements are inaccurate: the statute covers offering, paying, soliciting and receiving, and the guidance names two laws, so this pair excludes both true statements.