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

Correct Answer: Flexibility and scalability

HHS recognizes that covered entities range from the smallest provider to the largest multi-state health plan, so the flexibility and scalability of the Rule let each entity implement solutions suited to its business, size and resources. Option a is incorrect because this is an individual's right to request an alternative means or location for receiving protected health information, not a principle about adapting administrative measures to entity size. Option b is incorrect because this requirement covers members of the workforce such as employees, volunteers and trainees, and it does not address tailoring solutions to the entity's environment. Option d is incorrect because this is one specific administrative duty, assigning a person to develop and implement policies, and it does not describe how solutions vary with entity size.

Correct Answer: Refraining from intimidating or retaliatory acts

Under the standard on refraining from intimidating or retaliatory acts, a covered entity may not intimidate, threaten, coerce, discriminate against, or retaliate against an individual for exercising a right, including filing a complaint. Option a is incorrect because this standard directs discipline of workforce members who fail to follow privacy policies, so it governs staff conduct rather than protecting a person who files a complaint. Option c is incorrect because it bars requiring individuals to give up their rights as a condition of treatment, payment, enrollment or benefits; the scenario involves a response to a filed complaint instead. Option d is incorrect because this standard concerns reducing known harmful effects of an improper use or disclosure of protected health information, not how a covered entity treats an individual who complains.

Correct Answer: Make available information for an accounting of disclosures

The business associate contract must provide that the business associate will make available the information required to provide an accounting of disclosures, in accordance with the accounting provision, so the covered entity can answer such requests. Option b is incorrect because this duty obliges the business associate to notify the covered entity of impermissible uses, including breaches, and does not supply data for disclosure listings. Option c is incorrect because this provision follows the access requirement, which gives individuals the right to inspect and obtain their own information, not a list of disclosures. Option d is incorrect because this provision ties to the amendment right and requires incorporating amendments, which concerns changing record content rather than listing disclosures that were made.

Correct Answer: Provide access to the documentation

Under 42 CFR 424.516(f), a provider or supplier that furnishes covered ordered, certified, referred, or prescribed services must, upon request of CMS or a Medicare contractor, provide access to the required documentation. Option a is incorrect because the regulation directs access to CMS or a Medicare contractor, not delivery of the documentation to the beneficiary, who is not named as a recipient. Option c is incorrect because an ABN concerns the beneficiary's knowledge of financial liability and is a separate notice; it does not stand in for orders or payment request records. Option d is incorrect because the ordering physician has a parallel duty to maintain and give access on request, but the supplier's duty runs to CMS or the contractor.

Correct Answer: Records retention system

OIG guidance for physician practices suggests a records retention system that establishes standards and procedures regarding the creation, distribution, retention, and destruction of documents, supporting the practice if its compliance efforts are ever questioned. Option a is incorrect because OIG Special Fraud Alerts help a practice keep standards current on kickback and self-referral law, but they do not set document handling procedures. Option b is incorrect because safe harbors are OIG-published conditions describing practices not subject to the anti-kickback statute, not a method for handling document creation, retention and destruction. Option c is incorrect because a binder is a tool the designated compliance contact might keep for compliance documents, whereas the system sets standards across creation, distribution, retention and destruction.

Correct Answer: Signature log process

Medicare review guidance states that when a required signature is not met because it is illegible, the contractor may use the signature log process to try to resolve the issue. Option a is incorrect because it is the process offered when a required signature is missing and no rule demands the signature be in place before a given event or date, not for illegibility. Option c is incorrect because referral to the UPIC applies when reviewers identify documentation with potentially fraudulent entries, which is a different concern from an unreadable signature. Option d is incorrect because a delayed entry addresses services documented after they were rendered, with an identifiable date and author, and does not address how to interpret an illegible signature.

Correct Answer: Termination

A termination is the discontinuation of certain items or services. The ABN is issued at termination only if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary. Option a is incorrect because a reduction is a decrease in a component of care, and the ABN is not issued for every reduction, only in the stated circumstance. Option b is incorrect because initiation is the beginning of a new patient encounter, plan of care or treatment, not the discontinuation of care that is no longer necessary. Option d is incorrect because continuation is not one of the ABN triggering events; the triggers are initiations, reductions and terminations.

Correct Answer: Prompt refund of funds collected from the beneficiary

A notifier who issues a defective ABN is likely financially liable and precluded from collecting funds from the beneficiary. Funds already collected require a prompt refund, and a failure to refund timely may result in sanctions. Option a is incorrect because that provision lets a notifier transfer liability only when adequate advance notice was furnished, which a defective ABN fails to demonstrate. Option b is incorrect because a notifier who gave defective notice cannot say it lacked knowledge, because issuing the notice is clear evidence that the notifier knew Medicare might not pay. Option c is incorrect because the usual and customary fee may be charged only after a properly delivered ABN, and a defective ABN precludes the notifier from collecting from the beneficiary.

Correct Answer: Issue a new ABN

Under the period of effectiveness rule, an ABN remains effective only while care, the beneficiary's health status and Medicare coverage guidelines do not change. If any of these changes during treatment, a new ABN must be issued. Option b is incorrect because an ABN stays effective only while care, health status and coverage guidelines remain unchanged, and here the health status has changed. Option c is incorrect because the guidance ties a new ABN to the change itself, not to a request from the beneficiary, so waiting for one is not the rule. Option d is incorrect because the one-year point applies to repetitive or continuous care when no change has occurred, whereas a change during treatment calls for a new ABN.

Correct Answer: Establish beneficiary knowledge of non-coverage

Under the limitation on liability provisions, the ABN is the way a notifier establishes beneficiary knowledge of non-coverage, which allows financial liability to shift to the beneficiary if Medicare denies the claim. Option a is incorrect because an ABN is used when an item or service may be denied as not reasonable and necessary, so it signals a possible gap in necessity. Option b is incorrect because the ABN is a notice given to the beneficiary, not a request to the contractor, and it does not secure payment approval. Option c is incorrect because EMTALA obligations such as the medical screening examination come first, and written notices are delayed until they are met rather than serving them.