AAPC-CPMA Certified Professional Medical Auditor - Set 5 - Part 3

Correct Answer: Evidence or likelihood of fraud or abuse

The Medicare manual lists evidence or likelihood of fraud or abuse among the considerations for performing a provider/supplier site review, alongside aberrant billing patterns, multiple program integrity issues, and past failures to submit records timely. Option a is incorrect because sampling frame size relates to the sample and overpayment estimate, and the manual does not list it among considerations for choosing the review site. Option b is incorrect because the time limit for submitting documentation may be extended at the contractor's discretion, which concerns deadlines rather than where the review takes place. Option d is incorrect because appeal rights information is an element of the written notification itself and plays no role in selecting the review location.

Correct Answer: Requirement that every practice operate a formal hotline for reports

OIG recognizes hotlines as formal, costlier measures that do not suit some physician practices. A small practice may meet the communication element with an open door policy, so a mandatory formal hotline is not a listed feature. Option b is incorrect because OIG names a no-retribution provision in the standards and procedures as part of the system, so it is a genuine feature. Option c is incorrect because OIG lists this reporting requirement as a feature of the communication system, so it belongs to the set the stem describes. Option d is incorrect because the standards and procedures are described as stating that not reporting such conduct is itself a violation, which makes this a listed feature.

Correct Answer: Evaluating effectiveness of training and compliance messaging

OIG guidance encourages personnel to bring compliance questions to the compliance officer. Those questions are a useful source of information and can help evaluate the effectiveness of training and compliance messaging. Option a is incorrect because direct and uninhibited board access concerns the compliance officer's reporting relationship upward, and has nothing to do with staff questions. Option c is incorrect because oversight of the compliance officer is a board responsibility, not a benefit gained from employee questions reaching the compliance officer. Option d is incorrect because protection against retaliation is secured by written confidentiality and nonretaliation policies, which differ from using questions as a source of information.

Correct Answer: Enforce disciplinary policies against the supervisor

OIG guidance lists enforcing disciplinary policies and procedures as a prompt corrective action. It applies them to responsible individuals, including leaders or supervisors whose neglect or reckless disregard allowed the misconduct to occur unchecked. Option b is incorrect because OIG guidance says policies should be enforced against responsible individuals, including those in leadership or supervisory roles whose neglect allowed the misconduct, so no exemption exists. Option c is incorrect because refunding overpayments is only one listed corrective action; enforcing disciplinary policies and making policy or procedure changes are listed alongside it. Option d is incorrect because the guidance calls for prompt corrective action once enough credible information exists, and it does not tie discipline to the timing of any training program.

Correct Answer: Stipulated Penalties

Breach and default provisions of a corporate integrity agreement allow OIG to impose monetary penalties, referred to as Stipulated Penalties, when the entity fails to comply with the agreement. A material breach can also support exclusion. Option a is incorrect because describes a type of agreement that uses independent quality experts to review patient care delivery, not a monetary penalty for failing to comply. Option b is incorrect because is a reporting duty the entity owes OIG on its compliance activities; it is an obligation under the agreement, not a consequence of breach. Option c is incorrect because is a step an entity may take internally after detecting a violation, such as revising policies or training, rather than a penalty OIG imposes.

Correct Answer: Short-term monitoring

OIG guidance states that short-term monitoring is useful for determining the effectiveness of risk remediation. A brief, focused check after remediation to confirm the problem was resolved is exactly this activity. Option b is incorrect because it is a periodic exercise during which the entity may re-assess its monitoring program; it does not test whether a particular fix worked. Option c is incorrect because that review assesses how well each of the seven compliance program elements works overall, rather than confirming that one specific remediation succeeded. Option d is incorrect because it takes place during the investigation, so the entity can make changes preventing recurrence, and comes before any check of results.

Correct Answer: A lower multiplier on single damages

OIG states that persons who use the Self-Disclosure Protocol and cooperate with OIG deserve to pay a lower multiplier on single damages than would normally be required in resolving a Government-initiated investigation. Option a is incorrect because OIG guidance only describes a presumption against requiring integrity agreement obligations in exchange for release of permissive exclusion authorities, which is not a guarantee. Option b is incorrect because OIG guidance describes a 90-day timeframe for findings after the initial submission, which concerns the investigation report and not any added time to disclose. Option d is incorrect because the duty to report and return remains; the Protocol only suspends the deadline and may mitigate exposure under the overpayment statute.

Correct Answer: All other necessary corrective action

OIG expects the disclosing party to ensure the conduct has ended before disclosure, and all other necessary corrective action should be complete and effective at the time of disclosure under the Self-Disclosure Protocol. Option a is incorrect because a disclosing party unable to finish its internal investigation may certify that it will complete it within 90 days of the initial submission. Option b is incorrect because the submission may instead certify that the estimate will be sent to OIG within 90 days of submission. Option c is incorrect because a settlement agreement is reached after OIG accepts the submission, so it cannot be a prerequisite to disclosing.

Correct Answer: Promptly repay the overpayment to affected agencies

OIG guidance lists refunding of overpayments among prompt corrective actions. When misconduct resulted in an overpayment, the entity should promptly repay it to the affected government agencies, consistent with the federal 60-day requirement after identification. Option a is incorrect because policy and procedure changes address root causes of the misconduct, which is a different corrective action from refunding the overpayment to the program. Option c is incorrect because the guidance recommends at least an annual training program for individuals involved in coding and billing, which is an education measure and not the response to an overpayment. Option d is incorrect because disciplinary enforcement is a separate corrective action listed alongside refunding, and it does not itself return money to the affected government agencies.

Correct Answer: Sampling error

Sampling error is the natural variation that results from selecting a sample to represent a larger population. It decreases as the sample size increases, so selecting larger samples reduces it, as the scenario shows. Option a is incorrect because refers to how accurately a measure or conclusion reflects the real world, which is a different question from variation between random selections. Option b is incorrect because is a nonrandom method that uses readily available results and often yields biased data, whereas both groups here were chosen randomly. Option d is incorrect because describes a selection problem in which not all members of the population are equally likely to be chosen, not variation that shrinks with size.