AAPC-CPMA Certified Professional Medical Auditor - Set 5 - Part 2

Correct Answer: As a negative overpayment

Medicare program integrity guidance directs that sampling units found to be underpayments, in whole or in part, are recorded as negative overpayments and used in calculating the estimated overpayment, so they offset overpaid units. Option b is incorrect because underpaid units are not dropped from the sample; they stay in the calculation and reduce the estimated overpayment. Option c is incorrect because zero is reserved for units with a limitation on liability waiver or a without-fault determination, not for units found to be underpaid. Option d is incorrect because improper payment treatment applies to units whose requested records were not provided, which are counted as overpayments rather than underpayments.

Correct Answer: At least once a year

OIG guidance states that small entities should assess their compliance risks at least once a year. Entities that want to assess more often may do so, provided they dedicate the necessary time and resources to each assessment. Option a is incorrect because the guidance ties assessment to a regular schedule, not to an outside audit, and treats audits as one possible response after risks are identified and analyzed. Option b is incorrect because the Work Plan is described as a helpful resource for spotting potential risks, not as the trigger that sets how often an assessment occurs. Option c is incorrect because quarterly assessment is not the minimum the guidance sets; it describes more frequent assessments as optional for entities willing to dedicate the necessary time and resources.

Correct Answer: Conduct a joint risk assessment

OIG guidance says the Compliance Committee may find it helpful to have compliance, audit, quality, and risk management functions coordinate a joint risk assessment, which maximizes resources and reduces the number and potential redundancy of assessments. Option a is incorrect because OIG guidance mentions a billing contractor only as a possible way to access data, not as a way to consolidate assessments. Option b is incorrect because data analytics helps identify risk areas by highlighting outliers, but it supplements the formal assessment process and does not coordinate the separate functions. Option d is incorrect because the guidance makes the Compliance Committee responsible for conducting and implementing the assessment, working with the compliance officer to prioritize resources, so one person is not the answer.

Correct Answer: Conducting a compliance program effectiveness review

OIG guidance states that a compliance officer who does not receive audit or monitoring results raising concerns, or disclosure reports, over time should consider conducting a compliance program effectiveness review, which assesses how effective each program element is. Option a is incorrect because the guidance links outside experts to the board's option for the effectiveness review, based on resources and compliance history, not to a claims audit after silence. Option b is incorrect because the guidance describes this as a periodic or annual risk assessment task for deciding if monitoring is effective, still needed, or timed well; it is not the response to missing information. Option c is incorrect because the guidance treats a lack of concerns as a prompt for review, not a reason to cut audits; the work plan schedule rests on identified risks.

Correct Answer: Annual training for coding and billing staff

Annual training for coding and billing staff is an OIG recommendation for compliance education, not a billing risk area. The risk-area list covers problems such as duplicate billing, non-covered services billed as covered, and misuse of provider identification numbers. Option b is incorrect because OIG guidance names it as a billing risk area, describing it as billing for the same item or service more than once. Option c is incorrect because it appears in the same OIG list of coding and billing risk areas that have often drawn investigations and audits. Option d is incorrect because OIG guidance lists this among the billing risk areas, since it results in improper billing and has drawn frequent scrutiny.

Correct Answer: Improper payment, counted as an overpayment

Under the Medicare program integrity manual, sampling units for which the requested records were not provided are treated as improper payments, meaning overpayments, and they are included when the estimated overpayment is calculated. Option a is incorrect because the manual does not allow a unit to drop out for lack of records; it directs that such units be treated as overpayments. Option b is incorrect because BFL/COR approval is required when the contractor chooses not to give advance notice of the review, which is a different step from handling missing records. Option c is incorrect because negative overpayments are what the contractor records for sampling units found to be underpayments, whether in whole or in part, so missing records do not fit.

Correct Answer: I, II, and III

OIG guidance recommends evaluating selected claims to determine whether the codes billed and reimbursed were accurately ordered, performed, and reasonable and necessary for the treatment of the patient. Advance approval by a sponsoring provider is not part of that evaluation. Option a is incorrect because leaves out the medical necessity test, which the OIG names as part of the claim evaluation alongside ordering and performance of the service. Option c is incorrect because relies on statement IV, yet the guidance assigns no approval role to a sponsoring provider in claim evaluation, and it omits the ordering check. Option d is incorrect because includes advance approval by a sponsoring provider, which is not an evaluation element, and drops the check that the service was actually performed.

Correct Answer: OIG Work Plan

OIG guidance for physician practices points to the OIG Work Plan as the document that identifies vulnerabilities and risk areas on which OIG will focus in the future, making it a useful input for a practice's risk review. Option a is incorrect because these reports describe program vulnerabilities and risk areas OIG targeted during the preceding six months, so they look backward instead of forward. Option b is incorrect because this is a U.S. General Accountability Office publication with a section on risk assessments, not an OIG document identifying upcoming enforcement focus. Option d is incorrect because this was published by compliance professional organizations with COSO as guidance on conducting a compliance risk assessment, and it is not an OIG publication.

Correct Answer: binder

OIG guidance on standards and procedures for retention of records suggests the designated compliance contact could keep an updated binder or record of compliance, business and medical records, including compliance activity information. Option a is incorrect because Special Fraud Alerts are issued by the OIG on kickback and self-referral arrangements; a practice may obtain copies but does not create them. Option b is incorrect because claims denial history is described as something a practice reviews to find repeated overpayments, not as the compliance contact's record of compliance documents. Option c is incorrect because the OIG Work Plan is an OIG publication listing planned audits and evaluations, so a practice consults it rather than maintains it.

Correct Answer: Whether, and what kind of, reporting to the Government is necessary

OIG guidance states that allegations of noncompliant conduct should be investigated and that the investigation outcome should determine whether, and what kind of, reporting to the Government is necessary. Option b is incorrect because root-cause analysis is a process compliance programs should include for any identified impropriety, so it is not something the investigation outcome decides. Option c is incorrect because coordination with entity counsel is described as something the compliance officer does as needed upon receiving reports, which happens before the outcome is known. Option d is incorrect because the guidance says the existence or amount of monetary loss is not solely determinative of a violation, and material violations can exist without any loss.

Correct Answer: Policy and process revisions, personnel education, training plan revision, and consequences for offending individuals

OIG guidance states that a corrective action plan may include policy and process revisions, education of personnel, a revision to the entity's training plan, and consequences for offending individuals. Option a is incorrect because this describes the investigation stage, where the compliance officer decides whether a violation exists, which comes before corrective action. Option b is incorrect because these are separate steps listed beside a corrective action plan, not content of the plan itself. Option d is incorrect because these belong to enforcing standards, an element that is designed to be in place before violations occur, not to a corrective plan.

Correct Answer: Retention of an independent review organization

A corporate integrity agreement requires the entity to retain an independent review organization to conduct reviews. Its subject matter varies with the underlying conduct, and a case involving fraudulent billing would have a claims review. Option b is incorrect because this requirement creates a channel for reporting concerns and does not involve an outside party examining the entity's claims. Option c is incorrect because a compliance committee is an internal body appointed by the entity, so it cannot be the outside party that performs the required reviews. Option d is incorrect because this requirement governs who may be hired by the entity and has no role in reviewing claims.

Correct Answer: OIG

Under the OIG self-disclosure requirements for false billing conduct, the disclosing party estimates damages through its own review, and OIG verifies the disclosing party's calculation of damages. Option a is incorrect because a clinician reviews medical necessity within claims audits, which is a separate task from verifying the damages calculation submitted in a disclosure. Option b is incorrect because such an expert revises an overpayment estimate after an appeal finds a flaw, which is a Medicare contractor step, not a disclosure verification. Option d is incorrect because the committee builds the compliance work plan and audit schedule from risk assessment, but the guidance does not give it the verification of damages.

Correct Answer: Authority in effect when the service was provided

Medicare guidance states the review decision is made on Medicare law, CMS rulings, regulations, national coverage determinations, Medicare instructions and local medical review policies that were in effect when the item or service was provided. Option a is incorrect because an exit meeting only lets the contractor discuss preliminary findings and hear comments; it does not determine which rules govern the decision. Option c is incorrect because payment date does not set the standard; Medicare guidance ties the decision to the date the item or service was provided. Option d is incorrect because the review decision rests on the authority in force at the time of service, not on policies in place when the contractor started reviewing.

Correct Answer: An opportunity to discuss or comment

The Medicare manual states that at an exit meeting the contractor may discuss basic or preliminary findings and shall give the provider or supplier an opportunity to discuss or comment on the claims decisions made. Option a is incorrect because a settlement agreement is tied to the OIG self-disclosure process, and the Medicare manual does not call for one at an exit meeting. Option b is incorrect because the manual says the contractor need not hold up the review for late documents, so no extension is part of the exit meeting. Option d is incorrect because the sampling results are detailed later in a demand letter sent if an overpayment is determined, not delivered at the exit meeting.

Correct Answer: On a case-by-case basis

OIG guidance states that whether a material violation of applicable law exists must be determined on a case-by-case basis. Monetary loss is not solely determinative, and reporting may still be needed when no loss occurred. Option a is incorrect because the guidance describes no payer-set threshold; it leaves each determination to the facts of the particular case instead of a preset cutoff. Option c is incorrect because annual training is a separate education element for coding and billing staff and plays no role in deciding whether a material violation exists. Option d is incorrect because OIG guidance states that the existence or amount of a monetary loss to a Federal health care program is not solely determinative of a violation.

Correct Answer: It is one expected outcome the program plans for

OIG guidance states an investigation could show nothing improper occurred, reveal an overpayment, or uncover misconduct. A compliance program should expect any outcome on this spectrum and plan for it through appropriate policies and resources. Option a is incorrect because disciplinary policies are enforced against responsible individuals when misconduct is found; the guidance gives no basis for disciplining someone whose concern proved unfounded. Option b is incorrect because reporting to government agencies or law enforcement is tied to violations that are found and remediated, where appropriate, not to findings of no misconduct. Option c is incorrect because OIG guidance treats a finding that nothing improper occurred as a legitimate result of an investigation, not as evidence that the process failed.

Correct Answer: Personnel Qualifications

The report must list Personnel Qualifications: the names and titles of the individuals who conducted the review. The report should also describe their qualifications, such as statisticians, accountants, auditors, consultants or medical reviewers. Option b is incorrect because identifies the characteristics used to test each item, such as what must exist for an item to be a duplicate. Option c is incorrect because is a statement articulating the purpose of the review and does not name or describe the reviewers. Option d is incorrect because describes the data reviewed, including payment data sources and documents relied upon, rather than the individuals who conducted the review.

Correct Answer: Description of the statistically valid sampling and extrapolation methodology

When a person calculates an overpayment using a statistical sampling methodology, the reporting rule requires the report to describe the statistically valid sampling and extrapolation methodology used to reach the amount. Option a is incorrect because this is an element of the contractor's written notification of review sent to the provider, not part of an overpayment report. Option c is incorrect because the contractor includes this in its notification of review; a person reporting an overpayment is not required to supply it. Option d is incorrect because review location belongs in the contractor's notice to the provider or supplier and does not describe the sampling method in a report.

Correct Answer: Deny the claims without documentation

The contractor advises the provider that documentation not submitted or made available by the end of 30 calendar days leads to the review starting and denial of the claims for which there is no documentation. Option a is incorrect because the contractor starts the review when the time limit ends, so the review proceeds rather than waiting on the missing records. Option b is incorrect because the guidance gives no reduced payment for missing records; claims lacking documentation are denied once the 30 calendar days pass. Option c is incorrect because a fraud referral is described only as an extenuating circumstance that may delay completion, not as the response to undocumented claims.