AAPC-CPPM Certified Physician Practice Manager - Set 1 - Part 2

Correct Answer: That the individual agreed to the disclosure

The burden of proof covers demonstrating that notifications were made as required and, under the regulation, that a use or disclosure was not a breach. The statute adds evidence of necessity for any delay. Individual agreement is not listed. Option a is incorrect because the regulation on burden of proof lets the entity show that the use or disclosure did not constitute a breach as defined. Option b is incorrect because the statute extends the burden to evidence demonstrating the necessity of any delay, so this is a matter the entity must prove. Option c is incorrect because both the statute and the regulation place on the covered entity or business associate the burden of demonstrating that notifications were made as required.

Correct Answer: Whether the information can be further exchanged for remuneration by the recipient

HITECH bars exchange of protected health information for remuneration unless the covered entity obtained a valid authorization under the HIPAA authorization rule. That authorization must specify whether the recipient may further exchange the information for remuneration. Option a is incorrect because the statute assigns the minimum necessary determination to the covered entity or business associate making the disclosure, so it is not an element the authorization must specify. Option b is incorrect because a price tied to preparation and transmittal costs is a condition of the research exception, and it is not content required in the authorization. Option d is incorrect because the effective date only sets when the remuneration prohibition applies to exchanges, six months after final regulations are promulgated, and says nothing about authorization content.

Correct Answer: The Secretary

Under the HITECH provision on studies, reports and guidance, the Secretary prepares and submits the annual report on complaints of alleged violations to the Senate and House committees, beginning with the first year after enactment. Option b is incorrect because a covered entity is a regulated party whose compliance is the subject of the complaints; the statute assigns the report to someone else. Option c is incorrect because this committee is one of the recipients of the annual report, so it receives the report rather than preparing it. Option d is incorrect because a business associate is bound by the same requirements and is not given any reporting duty to Congress by this provision.

Correct Answer: Data on measures needed to evaluate quality of care

Under the quality and other reporting requirements, an ACO submits data in a form and manner specified by the Secretary on measures the Secretary determines necessary to evaluate the quality of care the ACO furnishes. Option a is incorrect because the agreement period is a participation requirement made with the Secretary, not data submitted to evaluate the quality of care. Option b is incorrect because the legal structure is a separate ACO requirement for receiving and distributing shared savings payments, not data reported on quality measures. Option d is incorrect because that application is required only from an ACO seeking to operate such a program, and it is not the quality data submission.

Correct Answer: OIG authority to obtain information

The statute lets the Inspector General obtain information from providers, suppliers and others to protect program integrity. This includes supporting documentation necessary to validate claims for payment under the Medicare and Medicaid titles. Option b is incorrect because these agreements let the Secretary exchange records with Social Security, Veterans Affairs, Defense and Indian Health Service officials to identify potential fraud, not to collect provider documentation. Option c is incorrect because the repository is a CMS database of claims and payment data from several programs, not a power to demand documentation from providers. Option d is incorrect because screening applies to provider enrollment, using checks such as licensure and site visits, and does not govern requests for claim support.

Correct Answer: National provider identifier

Section 1128J(e) directs the Secretary to require, by regulation, that qualifying providers and suppliers include their national provider identifier on all applications to enroll and on all claims for payment under Medicare and Medicaid. Option a is incorrect because the statute's inclusion requirement for applications and claims names the national provider identifier, and it does not name a tax identification number for that purpose. Option b is incorrect because the Integrated Data Repository is a CMS database holding claims and payment data from several programs, not an identifier providers place on applications or claims. Option d is incorrect because a moratorium is a temporary halt the Secretary may impose on enrolling new providers, and the statute describes no number of that name.

Correct Answer: New civil monetary penalty ground

The Affordable Care Act added civil monetary penalty grounds, including ordering or prescribing a medical or other item or service during a period of exclusion when the person knows or should know a claim will be made. Option a is incorrect because that protocol gives providers a route to disclose actual or potential self-referral violations; it does not penalize ordering during exclusion. Option b is incorrect because that provision applies to states that fail to report enrollee encounter data timely, so it targets states rather than individual providers. Option c is incorrect because that exclusion ground concerns a person who obstructs an investigation or audit, not one who orders items while already excluded.

Correct Answer: Return the funds erroneously claimed

OIG guidance states that when a practice finds billing errors, honest mistakes, or negligence produced erroneous claims, it should return the funds claimed in error, without penalties. Absent a violation of law, return of funds is the only result. Option a is incorrect because criminal penalties require criminal intent to defraud proved beyond a reasonable doubt, a standard far above an innocent billing error. Option c is incorrect because exclusion is a consequence of violating fraud and abuse laws, and innocent errors or negligence draw no administrative penalties under OIG guidance. Option d is incorrect because the Civil Monetary Penalties Law uses the same standard as the False Claims Act, which does not reach mistakes, errors, or negligence.

Correct Answer: 2 times the damages

If the court finds the person furnished all information within 30 days, fully cooperated, and met the timing conditions, the court may assess not less than 2 times the Government's damages, instead of 3 times. Option b is incorrect because 3 times is the multiple attached to ordinary liability under the general provision; the reduced damages provision states a lower minimum of 2 times. Option c is incorrect because the reduced damages provision sets its lower limit at 2 times the Government's damages, so a single-damages assessment falls below that stated limit. Option d is incorrect because the statute shows 3 times for ordinary liability and 2 times as the reduced minimum, so 4 times matches neither stated multiple.

Correct Answer: Reduction of damages

Reduced damages is a separate provision allowing a court to assess not less than 2 times damages for a cooperating violator. It is not retaliation. The anti-retaliation provision lists discharge, demotion, suspension, threats, and harassment. Option a is incorrect because the statute names being demoted as retaliation that entitles the employee, contractor, or agent to relief that makes them whole. Option b is incorrect because the relief provision lists being harassed as prohibited retaliation, so it belongs within the set the stem describes. Option d is incorrect because the anti-retaliation provision expressly lists being suspended among the prohibited actions taken because of lawful acts to stop violations.

Correct Answer: Payers and recipients are both covered, with each party's intent assessed

The AKS covers payers of kickbacks, who offer or pay remuneration, and recipients, who solicit or receive it. Each party's intent is a key element of that party's own liability, so the supplier is not excused by the physician's role. Option a is incorrect because a physician can violate the AKS even when the service was rendered and medically necessary, so necessity does not limit coverage of payers. Option b is incorrect because the statute reaches those who offer or pay remuneration as well, so a supplier giving free rent is exposed to liability too. Option c is incorrect because each party's intent is a key element of that party's own liability, which is therefore determined separately rather than derived from the other's.

Correct Answer: Civil money penalty for each arrangement or scheme

The statute subjects any physician or entity that knowingly enters into a circumvention arrangement or scheme, such as a cross-referral arrangement, to a civil money penalty for each such arrangement or scheme. Option a is incorrect because a per-day penalty applies to a failure to meet the reporting requirement for ownership and compensation information, which is a different violation. Option b is incorrect because the refund duty falls on a person who collected amounts billed in violation of the prohibition, which is a separate sanction from scheme liability. Option d is incorrect because payment denial attaches to a designated health service provided in violation of the referral prohibition, not to the act of creating a scheme.

Correct Answer: Strict liability; proof of intent is not required

The PSL is a strict-liability statute, which means proof of intent to violate the law is not required. Once all six elements are present and no exception applies, the referral is prohibited. Option b is incorrect because a financial relationship may be an ownership or investment interest or a compensation arrangement, and liability does not depend on a written contract being proven. Option c is incorrect because the standard is not tied to carelessness in billing; strict liability means the prohibition applies once the six elements exist and no exception is met. Option d is incorrect because the PSL is described as a strict-liability statute, so a prosecutor does not have to show that the physician intended to violate the law.

Correct Answer: Deliberate ignorance or reckless disregard of truth

The statute defines "should know" as acting in deliberate ignorance or in reckless disregard of the truth or falsity of information, and it adds that no proof of specific intent to defraud is required. Option a is incorrect because the statute does not treat an honest clerical mistake as meeting this standard; it requires deliberate ignorance or reckless disregard instead. Option c is incorrect because the statute states that no proof of specific intent to defraud is required, so intent is not what the term describes. Option d is incorrect because knowing of an overpayment is a separate ground in the penalty provision, distinct from the defined term "should know."

Correct Answer: Acceptance of a nolo contendere plea by a court

The statute treats an individual or entity as convicted when a Federal, State, or local court accepts a plea of guilty or nolo contendere, in addition to a judgment or a finding of guilt. Option b is incorrect because license suspension is a separate permissive exclusion ground, not a circumstance in the definition of 'convicted,' which depends on court proceedings or similar arrangements. Option c is incorrect because a payer's civil complaint is not among the listed circumstances; the statute ties conviction to a court judgment, finding of guilt, accepted plea, or diversion-type program. Option d is incorrect because a subpoena is an investigative step, and the statute's definition does not list it; conviction requires a court action or participation in a program withholding judgment.

Correct Answer: Exclusion from Medicare and State health care programs

A responsible physician who negligently violates EMTALA faces a civil money penalty. If the violation is gross and flagrant or is repeated, the physician also faces exclusion from participation in Medicare and State health care programs. Option a is incorrect because the statute lists no license revocation; the added sanction for a gross and flagrant or repeated violation is program exclusion. Option c is incorrect because the civil action for personal harm is brought against the participating hospital, not against the physician, so it is not the physician's added sanction. Option d is incorrect because the hospital's participation is not the consequence the statute attaches to the physician's own violation; the physician faces a penalty and possible exclusion.

Correct Answer: Double taxation of profits

Double taxation of profits is listed among the disadvantages of corporations, alongside the cost and complexity of formation and government restrictions. It is the only option that concerns how corporate profits are taxed. Option a is incorrect because this is named as a downside of partnerships, not as a disadvantage in the corporate list. Option b is incorrect because guidance ties this weakness to sole proprietorships, where one owner supplies the management, rather than to the corporate structure with its board and officers. Option c is incorrect because unlimited liability is listed as a disadvantage of sole proprietorships and general partners, whereas corporations are described as offering limited liability.

Correct Answer: Enforcing Standards: Consequences and Incentives

Enforcing Standards: Consequences and Incentives is one of the seven elements in OIG guidance. A program with no process to discipline staff who violate standards lacks this element, even if training is already provided. Option b is incorrect because this element concerns evaluating compliance risk and checking claims over time; it does not address what happens to staff who break standards. Option c is incorrect because the practice already provides regular instruction on billing rules and fraud risks, so this element is in place and is not the gap described. Option d is incorrect because this element covers documenting the practice's standards and procedures, whereas the missing piece is the consequence applied when someone violates them.

Correct Answer: Written notification by first-class mail

The Breach Notification Rule and HITECH require individual notice in written form by first-class mail to the last known address. Electronic mail replaces mail only when the individual agrees or specifies it as a preference. Option a is incorrect because it is a substitute form of notice, which applies when contact information is insufficient or out of date, and that is not the situation described here. Option b is incorrect because e-mail is allowed when the individual specifies it as a preference or agrees and has not withdrawn that agreement, and no such agreement exists here. Option d is incorrect because it serves as an alternative to home page posting in substitute notice when 10 or more individuals lack sufficient contact information, so it does not fit a single valid address.

Correct Answer: Confidentiality and nonretaliation policies

Under Element 4, OIG guidance calls for written confidentiality and nonretaliation policies distributed to all employees. They encourage communication with the compliance officer and the reporting of incidents of potential fraud and other compliance concerns. Option a is incorrect because incentives are examined by the Compliance Committee for unintended consequences, such as encouraging risky behavior, and are not the tool that supports reporting. Option c is incorrect because the work plan comes from the Compliance Committee's risk assessment and guides audits and monitoring; it does not protect employees who report concerns. Option d is incorrect because these belong to Element 7, which covers the response after audit results or reports raise concerns, not the protection of those who report.