AAPC-CPPM Certified Physician Practice Manager - Set 3 - Part 2

Correct Answer: Thirty days

Under the validation of debts provision, the notice must state that unless the consumer disputes the validity of the debt within thirty days after receipt of the notice, the debt collector will assume the debt is valid. Option a is incorrect because three business days is the shortest point in the window for notifying a person before depositing a postdated check, not a dispute period. Option b is incorrect because ten business days is the outer limit of the postdated-check deposit notice, which belongs to a separate unfair-practice provision. Option d is incorrect because five days is the limit for the debt collector to send the notice after initial communication, not the consumer's dispute period.

Correct Answer: Limitation on Liability

The Limitation on Liability (LOL) provisions apply to all Part A services and all assigned claims for Part B services. The refund requirements instead cover medical equipment and supplies and unassigned physicians' services claims. Option a is incorrect because Medicare guidance states that refund requirements do not apply to claims for Part A services, so no such protection exists there. Option b is incorrect because it covers assigned and unassigned claims for medical equipment and supplies, which is a far narrower category than Part A services generally. Option c is incorrect because it reaches only unassigned claims for physicians' services, so it leaves out Part A services and assigned Part B claims.

Correct Answer: Protecting beneficiaries and providers from unexpected liability for charges on claims Medicare does not pay

The financial liability protection provisions of the Act protect beneficiaries, healthcare providers, and suppliers, under certain circumstances, from unexpected liability for charges associated with claims that Medicare does not pay. They apply after coverage is determined. Option a is incorrect because the protections operate after the coverage determination for an item or service has been made, so they do not decide coverage. Option c is incorrect because in most cases the provisions apply only to beneficiaries in Original Medicare FFS Parts A and B, and they do not widen enrollment. Option d is incorrect because the provisions address who bears liability when Medicare does not pay a claim; they do not promise payment of every submitted claim.

Correct Answer: Healthcare provider or supplier liability

The contractor first decides whether the beneficiary is liable. When that is not established, it determines whether the healthcare provider or supplier knew or should have known. Only if neither is liable does Medicare accept liability. Option a is incorrect because this concerns appeal rights, where payment made under section 1879 is disregarded; it is not a step for assigning liability. Option b is incorrect because this is the first determination in the sequence and has already been made here, with the beneficiary not found to have had knowledge. Option c is incorrect because the program accepts liability only at the end of the sequence, after the healthcare provider or supplier has also been evaluated and not found liable.

Correct Answer: Presumed to have knowledge, and liable

When a provider cannot show the beneficiary received proper written notice, the provider is presumed to have knowledge and thereby liability, unless it proves it did not know and could not reasonably have been expected to know. Option a is incorrect because beneficiary liability rests on the beneficiary's own knowledge, such as a valid notice or an admission, and a missing notice does not create it. Option c is incorrect because the guidance places the presumption the other way when written notice cannot be shown; the provider must prove it lacked knowledge to escape liability. Option d is incorrect because Medicare pays only when the provider makes a convincing showing that it did not know and could not reasonably have been expected to know.

Correct Answer: Beneficiary enrolled in a Medicare Advantage plan

The Medicare manual names three situations where either party can be notifier: ordering and rendering providers, technical and professional components, and a signature-obtaining entity that differs from the billing entity. Plan enrollment type is not among them; the ABN recipient is an Original Medicare FFS beneficiary. Option b is incorrect because this is a listed situation: a physician orders a lab test and an independent laboratory delivers it, so either party may be notifier. Option c is incorrect because one laboratory referring a specimen to another laboratory that bills Medicare is the guidance's example, so either party can give notice. Option d is incorrect because guidance lists this case, such as an independent diagnostic testing facility rendering a radiological test while a physician interprets it.

Correct Answer: Notify the recipient in writing of the reason

Under the statutory duty to report and return overpayments, the person must also notify the Secretary, State, intermediary, carrier, or contractor in writing of the reason for the overpayment. Option a is incorrect because fair market value relates to payment for compliance services from referral sources under anti-kickback and Stark concerns, not to returning an overpayment. Option b is incorrect because a baseline audit is a monitoring tool in a voluntary compliance program, and the statute does not list it as part of returning funds. Option d is incorrect because the statute ties the cost report only to the deadline, as an alternative due date, and does not make it a step to request.

Correct Answer: Issue a new ABN

An ABN remains effective after valid delivery only while care, the beneficiary's health status and Medicare coverage guidelines stay unchanged. If any of these changes during treatment, a new ABN must be issued. Option a is incorrect because an ABN cannot be retroactively dated or used to shift liability for care already provided before the notice was issued. Option b is incorrect because the one-year interval is an option for repetitive care when nothing has changed, not a delay allowed after a change in the beneficiary's health status. Option c is incorrect because the original ABN stays effective only while care, health status and coverage guidelines are unchanged, and a change in health status ends that.

Correct Answer: Personal and full responsibility for payment

If the healthcare provider or supplier expects Medicare to deny payment, it must advise the beneficiary in advance that, in its opinion, the beneficiary will be personally and fully responsible for payment. Option a is incorrect because the manual does not tie advance notice to appeal rights; the required advice concerns who pays when Medicare denies the item or service. Option b is incorrect because Medicaid is named only as one possible payment source for the beneficiary, not as something the notifier must promise or assess in advance. Option d is incorrect because the guidance says nothing about discounted charges; the notifier advises that the beneficiary will be liable for payment, not that fees will drop.

Correct Answer: Full payment is made through bundled payments

The Medicare manual states that notifiers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments, because the beneficiary would not otherwise be liable. Option a is incorrect because the manual does not bar an ABN here; a properly delivered ABN with the beneficiary's agreement to pay can make the beneficiary liable. Option c is incorrect because a request for an official payment decision is a beneficiary right under Option 1 and does not remove the ability to issue an ABN. Option d is incorrect because usual and customary fees may be charged and collected after a valid ABN, and funds are not limited to the Medicare fee schedule.

Correct Answer: Recruitment branding

Training objectives specify performance improvements, reductions in errors, job knowledge to be gained, and other positive organizational results. Recruitment branding is a recruiting activity that presents an accurate, positive image of the firm to those being recruited. Option a is incorrect because fewer errors is one of the measurable results that training objectives spell out for a training activity. Option b is incorrect because training objectives name the performance improvements expected, which ties directly to the goal of increasing job performance through training and development. Option d is incorrect because training objectives state what job knowledge the employee is expected to acquire, so this item belongs to the set they specify.

Correct Answer: Not a representative until a valid appointment is executed

A provider or supplier that files an appeal for a beneficiary is not, by filing, the beneficiary's representative. It must execute a valid appointment, as the Medicare appeals guidance requires, before acting in that role. Option b is incorrect because no appointment is needed only for a legal guardian, surrogate decision-maker, SSA-appointed representative payee, or someone authorized under State law, and a provider or supplier is none of these. Option c is incorrect because the guidance states that filing an appeal request for a beneficiary does not by itself make the provider or supplier a representative. Option d is incorrect because rights pass to a provider or supplier only through a valid transfer of appeal rights executed by the beneficiary, which this practice does not hold.

Correct Answer: no other party is available to appeal

Medicare appeals guidance lets a provider or supplier without an independent appeal right appeal when the beneficiary has died and no other party is available to appeal. The MAC must determine whether another party is available. Option a is incorrect because Medicaid State agencies gain party status only when they paid or may be liable and filed a timely request, so a refusal to pay gives the provider nothing. Option b is incorrect because neither the contractor nor CMS is a party at the redetermination or reconsideration levels, so its participation has no bearing on the provider's standing. Option c is incorrect because a letter to the last known address or the estate is one way the MAC determines whether another party exists; sending it grants no appeal right.

Correct Answer: Whether good cause exists

When a redetermination request appears late, the MAC makes a finding of good cause before taking any other action on the appeal. The MAC may extend the filing time limit only if good cause is shown. Option a is incorrect because affirmation describes an adjudicator upholding a prior determination, which comes only after the appeal is being decided, not as a threshold step on late filing. Option b is incorrect because the amount in controversy is a dollar threshold tied to certain higher appeal levels, and redetermination carries no monetary threshold in the appeals chart. Option d is incorrect because an appointed representative is simply an individual a party names to act in the claim or appeal, and it does not control the timeliness finding.

Correct Answer: QIC

After a redetermination by the MAC, the next level is reconsideration. The Where to File chart directs reconsideration requests for Part A, Part B and DME to the QIC. Option a is incorrect because this office receives requests for an ALJ hearing, which is the third level and follows reconsideration rather than redetermination. Option b is incorrect because the MAC is where the first level, redetermination, is filed; the provider has already completed that level and now needs the next one. Option c is incorrect because the Appeals Council reviews ALJ decisions at the fourth level, so it is two levels beyond a redetermination.

Correct Answer: Accept and consider it

Under the Medicare manual's evidence provision, appellants may submit written evidence and arguments about the claim at issue, and contractors must accept and consider any relevant documentation submitted. Option b is incorrect because the guidance directs the contractor to consider relevant documentation now; the entire case is sent on only if a reconsideration is later requested. Option c is incorrect because the guidance mentions UPICs only as background on statistical sampling used to estimate overpayments, not as recipients of appellant evidence. Option d is incorrect because the guidance describes the State as the submitter of a State-initiated appeal, not as a reviewer of documentation sent by other appellants.

Correct Answer: Date the decision letter is mailed to all parties

For affirmations (unfavorable decisions), the Medicare manual defines completion as the date the decision letter is mailed to all of the parties or their representatives, which satisfies the 60-day timely processing requirement. Option a is incorrect because reporting appeals data on the CMS Appeals Report is a separate MAC duty and does not define completion of the redetermination. Option b is incorrect because that date is the date of receipt, which starts the 60-day period; it does not mark when the redetermination is complete. Option c is incorrect because completion is tied to the act of mailing the letter to the parties, not to when any party gets it.

Correct Answer: The new denial carries no appeal rights

Medicare guidance states that a new denial caused by system edits after a favorable appeal carries full appeal rights. Saying it carries no appeal rights contradicts that rule, so it is not a possible result. Option a is incorrect because CMS guidance states favorable-decision adjustments process through CMS systems and may suspend due to system edits, so this is a recognized result. Option b is incorrect because guidance says an adjustment that cannot process to payment because of system-imposed limits, such as frequency limits or NCCI edits, may result in a new denial. Option d is incorrect because the Medicare manual specifically says a new denial arising this way is considered an initial determination within the appeals process, so it restarts that sequence.

Correct Answer: Overpayment

The statute defines an overpayment as any funds a person receives or retains under the Medicare or Medicaid titles to which the person, after applicable reconciliation, is not entitled under those titles. Option a is incorrect because describes what an overpayment becomes for False Claims Act purposes when it is retained past the reporting deadline, not the term for the funds themselves. Option b is incorrect because is a document whose due date can set the return deadline, so it does not name funds a person is not entitled to. Option c is incorrect because is the adjustment step applied before deciding entitlement to funds; it is a process, not the name for the funds retained.

Correct Answer: Appropriate response to an identified problem

OIG guidance calls an appropriate response to an identified problem one of the most important components of a compliance audit protocol. The action should be prompt, and information on identification and on the practice's solution should be preserved. Option a is incorrect because this is a documentation-quality method that benchmarks the practice against others in the same specialty; it does not prescribe timing or record keeping after a problem. Option c is incorrect because it describes using training or policies from another entity, with fair market value concerns under the anti-kickback and Stark laws, not responding to a found problem. Option d is incorrect because sampling is a way to choose the universe of claims to audit, which happens before any problem is found, not the response afterward.