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Additional Preparation Methods for the CPCO Exam

Medical Compliance Resources

Even though the CPCO exam does have a separate study guide, the medical compliance resources below will help applicants prepare themselves for the examination. Click on any section header to see the resources available for that section.

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History of healthcare compliance programs in the United States

Medicare: Concerns With Physicians at Teaching Hospitals (PATH) Audits
July 1998 report to Congress on PATH Audits, Criteria, and Findings

OIG Semiannual Report, April - Sep., 1999
A report of program history, industry guidance, and enforcement actions by the OIG

Comprehensive Error Rate Testing (CERT)
Overview and resources from CMS on the CERT program

Medicare FFS Error Rate, Nov. 2009
Medicare Improper Payments Report listing amount of improper payments by contractor type

Civil Monetary Penalties and Affirmative Exclusions
OIG archive of false claims settlements

Trustees Report Summary, Social Security and Medicare, 2011
Current status of Social Security and Medicare trust funds and projections of future expenditures

Federal Sentencing Guidelines

United States Sentencing Commission
Federal sentencing guidelines for organizations

OIG five point strategy

Daniel Levinson, Testimony before House Subcommittee on Health, Sep. 15, 2010
Outline of five principles to combat waste, fraud, and abuse

Daniel Levinson, Testimony before House Subcommittee on Health, Sep. 22, 2010
Description of the scope of Medicare fraud and abuse and recovery efforts

Individual Physicians and Small Group Practices

OIG Compliance Program for Individual and Small Group Physician Practices, Federal Register, Oct. 5, 2000
Provides guidance for individual physicians and small group practices to incorporate into a medical compliance program

Third Party Billing Companies and Clinical Laboratories

OIG Compliance Program Guidance for Third-Party Medical Billing Companies, Federal Register, Dec. 18, 1998
Provides guidance for third party medical billing companies to incorporate into a medical compliance program

OIG Compliance Program Guidance for Clinical Laboratories, Federal Register, Aug. 24, 1998
Provides guidance for clinical laboratories to incorporate into a compliance program

Documentation requirements

OIG Compliance Program for Individual and Small Group Physician Practices, Federal Register, Oct. 5, 2000
Provides guidance for individual physicians and small group practices to incorporate into a medical compliance program

Conflicts of Interest

Conflict of Interest in Medical Research, Education, and Practice; Chapter 6
Review of physician conflicts of interest along with recommendations

Controlling Conflict of Interest – Proposals from the Institute of Medicine, New England Journal of Medicine, May 21, 2009
Analysis of the Institute of Medicine's proposals for addressing physician conflicts of interest

Gifts/Gratuities

Subpart J-Financial Relationships Between Physicians and Entities Furnishing Designated Health Services
Electronic Code of Federal Regulations record of section defining improper physician referrals

Medical Necessity/Advance Beneficiary Notices

Medicare Claims Processing Manual, Chapter 30
Guidelines for using the Advance Beneficiary Notice of Noncoverage (ABN)

Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices (ABNs) of Noncoverage
Instructions for use of the GA and GX modifiers

Overpayments/Credit balances
Text of the Patient Protection and Affordable Care Act

Medicare Overpayment Collection Process
Fact sheet from CMS describing the process it follows to collect overpayments

Certificates of Medical Necessity

Medicare Program Integrity Manual, Chapter 5
Items and Services Having Special DME Review Considerations

Certification of Home Health/Hospice/Rehabilitative Therapy services

Medicare Benefit Policy Manual, Chapter 7
Home Health Services

Medicare Benefit Policy Manual, Chapter 9
Coverage of Hospice Services Under Hospital Insurance

Medicare Benefit Policy Manual, Chapter 15
Covered Medical and Other Health Services

Medicare General Information, Eligibility, and Entitlement; Chapter 4
Physician Certification and Recertification of Services

Non-covered services

Advance Beneficiary Notice of Noncoverage (ABN)
CMS booklet that describes when and how to use the ABN

Teaching physicians

Guidelines for Teaching Physicians, Interns, and Residents
Documentation and E/M guidelines for teaching physicians, interns, and residents

Medicare Claims Processing Manual, Chapter 12
Physicians/Nonphysician Practitioners

CMS Manual System, Medicare Claims Processing, Change Request 3928
Instructions for billing for teaching physician services

Gainsharing Arrangements

Gainsharing Arrangements and CMPs for Hospital Payments to Physicians
Defines and prohibits gainsharing arrangements from hospitals to physicians to reduce patient care

Recent Commentary Distorts HHS IG's Gainsharing Bulletin
Rebuttal by the Office of Counsel to the Inspector General against commentary criticizing the gainsharing bulletin

Joint Ventures

Special Advisory Bulletin, Contractual Joint Ventures
Bulletin describing and defining questionable contractual arrangements

OIG Special Fraud Alerts
Collection of five special fraud alerts, published in the Federal Register Dec. 19, 1994

Participating/Non-participating agreements

Private Contracting/Opting out of Medicare
Clarifies policy rules on opt-out status for Medicare

Rental of Office Space

Federal Register, Feb. 24, 2000
Special Fraud Alert: Rental of Space in Physician Offices by Persons or Entities to Which Physicians Refer

Following established policies/procedures

State escheat laws

The laws vary by state – need to understand general principles of state escheat laws

Difference between Fraud and Abuse

Definition and Examples of Fraud and Abuse
Kansas Department on Aging definition and examples of fraud and abuse

Defining Fraud and Abuse
Tennessee Inspector General defines difference between fraud and abuse

False Claims Act

False Claims
Section of U.S. Code defining false claims

Stark Laws

Stark Law Overview
Stark Law overview and resources provided by CMS

Limitation on Certain Physician Referrals
Section of U.S. Code defining improper physician referrals

Antikickback Statute

Federal Anti-Kickback Law and Regulatory Safe Harbors
Overview of safe harbors under the anti kickback law

Federal Register, Sep. 25, 2002
Medicare and State Health Care Programs: Fraud and Abuse; Safe Harbor Under the Anti-Kickback Statute For Waiver of Beneficiary Coinsurance and Deductible Amounts

Civil Monetary Penalties

Civil Monetary Penalties
Section of U.S. Code describing financial penalties for filing improper claims

Fraud Enforcement and Recovery Act (FERA)

Fraud Enforcement and Recovery Act (FERA)
Text of the Fraud Enforcement and Recovery Act of 2009

HIPAA

Health Information Privacy
HIPAA resources and information from HHS

EMTALA

Emtala.com web site
Resources and case histories for EMTALA

CLIA

Clinical Laboratory Improvement Amendments (CLIA)
CLIA overview and resource page from CMS

Patient Protection and Affordable Care Act (PPACA) 2010

Patient Protection and Affordable Care Act (PPACA) 2010
Text of the Patient Protection and Affordable Care Act

OSHA

Occupational Safety and Health Administration
Official Dept. of Labor OSHA site

Mail/Wire Fraud

Mail Fraud and Other Fraud Offenses
Section of U.S. Code defining mail fraud and other types of fraud

RICO (Racketeer Influenced and Corrupt Organizations Act)

Racketeer Influenced and Corrupt Organizations
Section of U.S. Code for RICO

Investigations process, Attorney-Client Privilege, Qui Tam, self-disclosure protocols

About Qui Tam
Overview of Qui Tam laws from the Bauman & Rasor Group

Self-Disclosure Information
Information and resources from the OIG for provider self-disclosure

Corporate Integrity Agreements (CIAs) and Certificate of Compliance Agreements (CCAs)

Corporate Integrity Agreements
Information and resources from the OIG on corporate integrity agreements

Checking for excluded parties

Exclusions Program
Information and resources from the OIG on exclusions from federally funded health care programs

Excluded Parties List System
Official government web site to search and identify excluded parties

RACs, ZPICs, MICs, PSCs, and MFCUs

Recovery Audit Program
Overview and resources from CMS on the RAC program

Medicare Program Integrity Manual, Chapter 4
Benefit Integrity

Medicare Program Integrity Manual, Chapter 2
Data Analysis

The Medicare Appeals Process
Fact sheet from CMS describing the five levels of the appeals process

RACaudits.com web site
Private party web site with RAC appeals resources

The Medicare Recovery Audit Contractor (RAC) Program: An Evaluation of the 3-Year Demonstration
June 2008 report on the first three years of the RAC program

National Correct Coding Initiative (NCCI) Overview
Overview of the NCCI program provided by CMS

GPO Access – U.S. Code
Searchable archive of the U.S. Code

Compilation of the Social Security Laws
Searchable archive of the laws governing Social Security

GPO Access – Federal Register
Searchable archive of the Federal Register

Balanced Budget Act of 1997
Text of the Balanced Budget Act of 1997

Patient Protection and Affordable Care Act (PPACA) 2010
Text of the Patient Protection and Affordable Care Act

Office of Inspector General
OIG main web site

OIG Compliance Guidance
Compliance guidance by type of provider or entity

Centers for Medicare & Medicaid Services
CMS main web site