HCCA - CHC Study Questions (MASTER FLASHCARDS)

True or False:

The ACA requires that all providers adopt a compliance plan as a condition of enrollment with Medicare, Medicaid, and Children's Health Insurance Program (CHIP).

True

ref. ACA section 6102

According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections)

1.Protect our programs

2.Protect your patients

3.Protect the Provider

https://oig.hhs.gov/newsroom/podcasts/2011/heat/heat09-trans.asp#:~:text=Proper%20documentation%2C%20both%20in%20patients,to%20protect%20you%20the%20provider.

At which level of the Medicare Part A or Part B appeals process is the appeal decision by the Office of Medicare Hearings and Appeals (OMHA)?

a. first level of appeal

b. second level of appeal

c. third level of appeal

d. fourth level of appeal

c. . third level of appeal

Frist level - redetermination by Medicare contractor

Second level - reconsideration by Independent contractor

Third appeal - Administrative Law Judge (ALJ) hearing

Fourth appeal - review by Medicare Appeals Council

Fifth appeal - review in Federal District Court

https://www.hhs.gov/about/agencies/omha/the-appeals-process/index.html

What should CCO be able to do? (What skills should this person have?) Choose all that apply.

a. Leadership skills.

b. Oversee the coding department.

c. Skills to design and implement a compliance program.

d. Be able to anticipate new risk areas.

e. Practical experience with documenting medical necessity.

a. Leadership skills,

c. Skills to design and implement a compliance program, and

d. Be able to anticipate new risk areas.

Which of the following is an absolute necessity in order to have a successful Compliance Program?

a. continuous training and improvements

b. effective reporting path

c. non-retaliation for whistleblowers

d. reliable and equal discipline

c. non-retaliation for whistleblowers

A Compliance Program with well written policies and procedures:

a. can be successful if consistently reviewed and maintained

b. cannot be effective due to the sheer volume presented

c. will be effective if read by management

d. will not be successful without the proper oversight

d. will not be successful without the proper oversight

Regardless of having the best written policies in place that are reviewed/maintained consistently, and read and disseminated accordingly, will fail if there is no proper oversight to ensure they are actually being followed and understood.

A Compliance Officer can achieve a higher level of compliance and ethics engagement by:

a. ensuring leadership reads the policies

b. increasing management involvement

c. responding to compliance hotline calls

d. monitoring the code of conduct

b. increasing management involvement.

Compliance is everyone's responsibility, but management involvement is crucial. They have a direct contact with employees, they know and understand their staff's needs and concerns, and have the most influence over employee's actions and attitudes. Employees most likely use their direct manager(s) to raise concerns and the reason they are so critical for an organization to foster a culture of compliance.

Which of the following requires providers to be permanently excluded from all federal health care programs if found guilty of a healthcare related fraud a third time:

a. Deficit Reduction Act of 2005

b. False Claims Act

c. Balance Budget Act of 1997

d. Social Security Act section 1128d

c. Balance Budget Act of 1997

Also known as a BBA "three strikes rule"

What section of the ACA prevents discrimination against individuals with limited English proficiency (LEP), and also prohibits discrimination in healthcare programs and activities that receive federal funding, based on race, color, national origin, sex, age, or disability.

a. ACA section 6102

b. ACA section 1557

c. ACA section 6002

b. ACA section 1557 is the correct answer.

a. ACA section 6102 requires owners, operators, and administrators of LTC facilities to adopt effective compliance.

c. ACA section 6002 requires the establishment of a transparency program, now known as CMS Open Payments.

Which statement is TRUE regarding compliance programs?

a. Compliance programs are considered more dangerous if they are developed but not implemented.

b. Compliance programs can detect but not prevent criminal conduct

c. Compliance programs are only required by law for healthcare entities that have more than $500,000 in annual revenue.

d. Compliance programs are not mandated by law.

a. Compliance programs are considered more dangerous if they are developed but not implemented.

An individual's understanding of the compliance aspects of their job can BEST be enhanced by including compliance in:

a. annual evaluations

b. exit interviews

c. HR benefit materials

d. audit committee meetings

a. annual evaluations

Formal statement outlining a plan for a specified subject area. It usually cites state and/or federal required actions or standards.

a. CAP

b. Procedure document

c. Policy document

d. Legal standards

c. Policy document

CAP - outlines corrective action plan

Procedure - describes process/steps under a certain criteria

Legal standards - mandatory action or rule

Life cycle of records management

Creation

Use

Maintenance

Retention

Disposition

Standards of Conduct (written P&Ps)

Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations

Code of Conduct: Content Checklist

• Demonstrate system wide emphasis on compliance with all applicable laws and regulations

• Written plainly and concisely so all employees can understand the standards

• Includes internal and external regulations

• Mentions organizational policies without completely restating them

• Is consistent with company policies and procedures

• Includes management's responsibility to explain and enforce the code

Ref: SCCE Compliance & Ethics Manual, Chapter 2

https://compliancecosmos.org/essential-elements-effective-ethics-and-compliance-program

Code of Conduct and Employees

All employees must receive, read, and understand the standards.

A supervisor should explain the standards and answer any questions.

Employee should attest in writing that they have received, read, and understood the standards

Employee compliance with standards must be enforced through appropriate discipline when necessary

Discipline for non-compliance should be stated in the standards

Code of Conduct Purpose

• To present specific guidelines for employees to follow

• To confirm that all employees comprehend what is required of them

• To provide a process for proper decision making

• To confirm that employees put standards into everyday practice

• To elevate corporate performance in basic business relationship

• To confirm that the organization upholds and supports proper compliance conduct

Every organization needs policies and procedures for:

• Internal assessments

• Record retention (where, how long)

• Self-disclosure

• Medicare sanction checks (LEIE)

• Billing policies

• Credit balance

• No charge visits

• Incomplete/unsuccessful procedure

• Documentation requirements

When should Code of Conduct be distributed to new employees?

Must be distributed within 90 days of hire

RAT-STATS is: (select all that apply)

a. statistical software to select randomized samples

b. government statistical rule software developed in the 1970s

c. free hospital statistical software

d. recommended by OIG, CMS and other agencies to select random samples

a. b. d.

The software can be used by other entities other than hospitals, so option "c." is not precisely accurate, but it is free to use and can be downloaded here: https://oig.hhs.gov/compliance/rat-stats/index.asp

What is the term called for an organization's commitment to compliance by management, employees, and contractors. Statement should summarize ethical behavior and legal principles under which the healthcare organization operates?

Code of Conduct

In the course of an audit, you find that disciplinary actions against certain physicians and high level executives for non-compliance in the organization have been unfair and inconsistent with current policies & procedures. What is your first course of action

.a. Work with legal counsel to enforce proper disciplinary actions

b. Get HR involved and recommend the use of progressive discipline policies

c. Immediately terminate these individuals

d. Get local and federal labor department involved for unfair discipline.

b. Get HR involved and recommend the use of progressive discipline policies

OIG recommends setting forth the degrees of disciplinary actions. Progressive discipline provides a structure and a set of discipline standards for managers/supervisors to follow to ensure discipline is fair, equitable and consistent.

Documentation

• A&M should be documented

• Findings should be shared with dept managers

• If activity is part of risk priority then compliance committee, senior leadership and board when necessary

• OIG calls for written evaluation to be presented to CEO, governing body, committee annually

Non-retaliation in compliance - what is important to state in this policy:

For any reporting method to be effective, employees must accept that there will be no retaliation or retribution for coming forward.

The concept of non-retaliation is fundamental to the compliance program, and a clearly stated policy regarding non-retribution is the first step.

• anonymous reporting and,

• no retaliation or retribution for bringing forth problems/concerns

Place to start with Enforcement is:

Standards of conduct and P&Ps

For Enforcement and Disciplinary Actions, Policies should include:

1. non-compliant consequences

2. employees duty to report non-compliance

3. list parties responsible for appropriate action

4. outline of disciplinary actions or procedures

5. promise that discipline will be fair and consistent

New Employee Policy - three checks OIG recommends to do/perform:

OIG recommends: perform background checks, reference checks, and exclusion list checks

Which two main documents become tools to build compliance program?

Code of Conduct and P&Ps

You are the new Compliance Officer, hired after ABC Hospital reorganized and decided that the General Counsel should no longer also serve in that role. Upon review of the Code of Conduct (CoC), you find that it is written using lots of legal jargon. What action do you take:

a. Keep CoC as it is.

b. Pull a sample off the internet and insert hospital name to save time as it was most likely written by experts.

c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance.

d. Rewrite the CoC with detailed restating hospital's P&Ps, and all laws and regulations possible so that employees can't say they were not aware of requirements.

c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance.

Explanation:

• CoC should be clear and concise language easy to understand, and should be tailored to specific issues of the organization

What is the term called for an organization's commitment to compliance by the board, management, and employees? It summarizes ethical behavior and legal principles the healthcare organization operates.

A) Code of Conduct

B) Federal Sentencing Guidelines

C) Internal Controls

A) Code of Conduct

The U.S. Federal Sentencing Commission was organized in _____, published its initial set of guidelines manual in _____ (known today as the US Sentencing Guidelines), and included chapter eight of the Federal Sentencing Guidelines for Organizations in _____.

a. 1980, 1987, 1999

b. 1985, 1987, 1991

c. 1980, 1985, 1987

d. 1985, 1990, 2001

b. 1985, 1987, 1991

The US Sentencing Guidelines (USSG) can be found here: https://www.ussc.gov/guidelines.

Chapter 8 - Sentencing of organizations, includes Parts A-F (Part B 2.b.1 outlines the Compliance and Ethics Program)

Expectations have evolved since 1991 when the US Sentencing Guidelines (USSG) were first drafted highlighting the importance of an effective compliance program (and as a condition of probation) to help detect criminal conduct (USSG chapter 8B2.1). DOJ has now set higher expectations for organizations to not only have a designated compliance officer but a well designed compliance program that is adequately resourced with independent authority function to work in practice. Which of the following guidelines outlines those expectations:

a. HHS OIG - CPG (Compliance Program Guidance)

b. DOJ ECCP (Evaluation of Corporate Compliance Programs)

c. Monaco Memo

d. HHS OIG - CIA (Corporate Integrity Agreement)

b. DOJ ECCP (Evaluation of Corporate Compliance Programs)

The ECCP and other related guidance can be downloaded here: https://www.justice.gov/criminal/criminal-fraud/policy-materials

The most updated DOJ ECCP (Evaluation of Corporate Compliance Programs) provides additional guidance to prosecutors. Which of the following are included in the ECCP revisions (Sep 2024)?

a. expects company's compliance program to include safeguards to better monitor and manage potential compliance risk regarding new technologies (e.g., A.I.)

b. expects company's to integrate these new technology related risks into broader enterprise risk management (ERM) strategies

c. expands on post-acquisition compliance integration and use of data for compliance purposes

d. all of the above

d. all of the above

The privacy officer for a hospital has updated the Notice of Privacy Practices/NPP to reflect a material change because the previous notice did not have a description that individuals have the right to amend their Protected Health Information. The 3rd party review team identified that the notice did not have the required information to let individuals know of their right to amend PHI. What's the BEST course of action to correct deficiency?

A. Make arrangements to mail the new NPP to all patients seen within the last year at the hospital

B. Make arrangements to have the new NPP distributed to new patients that come to the hospital

C. Post a copy of the new NPP on the hospital's internal intranet so that all employees can see the updated version of the notice

D. Meet with legal to discuss how to best self-disclose to OCR that the hospital was in violation of the NPP requirements and has since corrected the deficiency

B. Make arrangements to have the new NPP distributed to new patients that come to the hospital

Remember: The NPP must describe the following individual rights: https://www.law.cornell.edu/cfr/text/45/164.520

• The right to request restrictions on uses or disclosures of PHI for treatment, payment or healthcare operations; for use in a facility directory (if applicable); or to family members and others involved in the patient's care; however, the provider is not required to agree to the restriction except in the case of a disclosure to a health insurer if the individual has paid for the care as required by

§164.522(a)(1)(vi). This is a change necessitated by the Omnibus Rule.

• The right to receive confidential communications by alternative means or at alternative locations per §164.522(b).

• The right to inspect and copy PHI per § 164.524. The provider may want to include a statement that the provider may charge a reasonable cost-based fee for copies.

• The right to amend PHI per § 164.526.

• The right to receive an accounting of disclosures of PHI as provided by § 164.528.

• The right to receive a paper copy of the NPP upon request.

• A brief description of how the individual may exercise the foregoing rights, e.g., by submitting a written request to the provider's privacy officer.

What is the best definition of Medicare/Medicaid fraud?

a. Attempting a scheme against the Medicare/Medicaid program

b. Knowingly executing a scheme against the Medicare/Medicaid program

c. Willfully executing a scheme against the Medicare/Medicaid program

d. All of the above

d. All of the above

Remember: Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme.

FRAUD is intentional;

WASTE is overuse/misuse of resources carelessly;

ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses

What is the best definition of Medicare/Medicaid abuse?

a. Knowingly defrauding the Medicare/Medicaid program

b. Intentionally violating Medicare/Medicaid guidelines

c. Unknowingly violating Medicare/Medicaid guidelines

d. None of the above

c. Unknowingly violating Medicare/Medicaid guidelines

FRAUD is intentional (knowingly/willfully);

WASTE is overuse/misuse of resources carelessly;

ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses

A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from Medicare/Medicaid. Is this violation fraud, abuse, or neither?

a. Fraud

b. Abuse

c. Neither

a. Fraud

Upcoding - is a type of fraud (knowing/intentionally) coding more expensive codes for higher reimbursement

What is true about Medicaid Integrity Programs or MIPs:

a. established by the DRA of 2005

b. federally administered and state monitored

c. audited by MACs

d. created to combat Medicare provider FWA

a. established by the DRA of 2005 (section 6034)

https://www.ssa.gov/OP_Home/comp2/F109-171.html

Notes:

b. federally administered and state monitored (the opposite)

c. audited by MACs (MAC is for Medicare. MIPs are audited by MICs)

d. created to combat Medicare provider FWA (Medicaid, not Medicare)

Reporting systems should be:

a. marketed to contractors

b. outsourced to a vendor

c. operated by management

d. publicized to all employees

d. publicized to all employees

Are providers financially liable if their billing services commit fraud without the provider's knowledge?

Yes

No

Yes - they are financially liable for all claims submitted on their behalf that contain their identification number

Regarding patient credit balances, which of the following are good practices for addressing credit balance compliance risks:

a. Review reporting capability as most EHRs can detect a credit balance issue.

b. Perform root-cause analysis to determine the direct source of overpayment, and ongoing monitoring

c. Perform random audits and report findings to ensure proper monitoring and corrective action.

d. all of the above

d. all of the above

Having a clear P&P on overpayments, self-disclosure and credit balances is also recommended to stay up to date with regulatory changes and avoid any penalties

An employee reports a potential problem with the attending physician's presence for surgery. Which of the following is the compliance professional's BEST action?

a. investigate the issue

b. approach the surgeon

c. notify the OIG

d. request copies of the records

a. investigate the issue

The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean?

a. Persons reporting fraud or abuse may be subject to the same penalties as the persons committing the fraud or abuse.

b. Persons reporting fraud or abuse can be discharged or demoted.

c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.

d. Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position.

c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.

The entity's level of commitment to compliance is directly related to the resources (human and financial)

a. True

b. False

b. False

The code of conduct should address the organization's:

a. Culture

b. Beliefs

c. Ethical position

d. All of the above

d. All of the above

TRUE or FALSE:

Incentivizing ethical conduct or behavior creates a sense of accountability, fosters a culture of compliance, and naturally promotes ""do the right thing."

TRUE

Use incentives to promote commitment to compliance

When developing an effective code of conduct, an organization should consider:

a. Soliciting another organization's code and tweaking it to fit

b. Methods for reporting issues

c. Zero tolerance for fraud and abuse

d. B and C

d. B and C

Sue works for ABC Family Physicians. The providers at this office ask her to research the department that helps protect patients from unfair treatment or discrimination. What department or agency would that be?

a. Equality in Employment Agency

b. Office for Civil Rights

c. Department of Justice

d. Office of Inspector General

b. Office for Civil Rights (OCR)

DOL oversees employment discrimination

DOJ enforces federal criminal law and implements criminal law policies

OIG combats FWA in Medicare, Medicaid and HHS Programs

Note: practice question from AAPC CPCO Ch1

Which government department is comprised of thousands of employees who enforce the nation's federal criminal laws and help develop and implement criminal law policies?

a. Office of Inspector General

b. Centers for Medicare & Medicaid Services

c. Healthcare Lawyers Association

d. Department of Justice

d. Department of Justice

OIG combats FWA in Medicare, Medicaid and HHS Programs

CMS administers the nation's major healthcare programs including Medicare, Medicaid, and CHIP to eliminate FWA

HLA is an edu org (not a gov department)

Note: practice question from AAPC CPCO Ch1

Which department is the largest inspector general's office in the federal government?

a. HHS Office of Inspector General

b. Office of Civil Rights

c. Department of Justice

d. Centers for Medicare & Medicaid Services

a. HHS Office of Inspector General

Note: practice question from AAPC CPCO Ch1

What term would be used for actions that, either directly or indirectly, results in unnecessary costs to the Medicare program?

a. Fraud

b. Mistake

c. Waste

d. Abuse

d. Abuse

Abuse - Abuse is similar to fraud, except that the investigator cannot establish the act was committed knowingly, willfully, and intentionally. The difference between fraud and abuse is the individual's intent.

Fraud - knowingly/intentionally

Waste - overuse/misuse of resources

Note: practice question from AAPC CPCO Ch1

You are the new compliance officer for a hospital and see that it is currently under an OIG CIA. What would be the first course of action in your new position?

a. Review the current OIG Work Plan and update the audit schedule for the hospital.

b. Review the Code of Conduct and Policies and Procedures and update them as appropriate.

c. Meet with the Compliance Board and discuss your vision of how compliance will be run in the future.

d. Review the audit schedule and pick up where the previous compliance officer left off.

b. Review the Code of Conduct and Policies and Procedures and update them as appropriate.

A compliance professional is conducting a policy review. Which of the following procedures MUST be included in the policy for statistically valid sampling and extrapolation?

a. financial error rate exceeds 5% with a refund to occur within 60 days

b. financial error rate exceeds 5% with a refund to occur within 90 days

c. coding error rate exceeds 5% with a refund to occur within 60 days

d. coding error rate exceeds 5% with a refund to occur within 90 days

a. financial error rate exceeds 5% with a refund to occur within 60 days

Regarding statistical sampling, what is an example of failed efforts to use statistical analysis?

a. Users who did not understand subject matter or application of sampling.

b. A well-rounded data sample

c. Knowledgeable staff who are involved in the process

d. Investigations done of improper billing practices

a. Users who did not understand subject matter or application of sampling.

The use of qualified personnel and adequate resources is key. Use of experts, when appropriate.

True or False:

A hospital with an imposed-CIA performs a discovery sample as part of the Claim Review and finds it has a financial error rate above 5%. OIG requires that the hospital then conducts a full sample.

TRUE

Probe and Discovery Samples are used to get an initial glimpse and seriousness of a problem to determine if the size of a Full Sample is needed. For example, in Corporate Integrity Agreements (CIA) the OIG requires a Full Sample to be used, if the overpayment error rate, or financial error rate, in a Discovery Sample is at or above 5%.

https://oig.hhs.gov/faqs/corporate-integrity-agreements-faq.asp

https://www.americanbar.org/content/dam/aba/administrative/healthlaw/14_emerging_trends_in_false_claims_act_damages_settlements_07.authcheckdam.pdf

True or False:

If an IRO (independent review organization) identifies any underpayments during a CIA-Claim Review for a hospital, these may be netted (or offset) from overpayments. The hospital may also consult with the appropriate payor to ensure if the underpayment amounts can be used against outstanding overpayments.

TRUE

For purposes of reporting the overpayment to the OIG, underpayments may be netted (or offset) from overpayments. However, in terms of repaying the overpayment to the appropriate payor, the provider should consult with that payor as to whether it will allow underpayments to be netted from overpayments for collection purposes.

https://www.americanbar.org/content/dam/aba/administrative/healthlaw/14_emerging_trends_in_false_claims_act_damages_settlements_07.authcheckdam.pdf

The following questions would be pertinent to every organization to help the __________________ professional in reviewing policies and procedures that need to be addressed:

Does the organization employ non-physician practitioners?

Does the organization perform services in a rural clinic settings?

Does the organization provide medical services that fall under the Physicians at Teaching Hospital (PATH) rules?

Does the organization participate in clinical trials (research)?

a. Human Resources Director

b. Chief of Hospital Operations

c. Chief of Compliance

d. Medical Staff Services

c. Chief of Compliance

These are common questions that help a compliance officer in reviewing some common areas that policies and procedures may need to be addressed.

What is RAT STATS?

a. Government hotline for fraud and abuse

b. Government statistical rules (for example sample size)

c. Hospital technology for tracking sampling

d. Statistical software for hospitals to use

b. Government statistical rules (for example sample size)

The largest and oldest accrediting body for healthcare organizations in the United States, which has accredited more than 22,000 organizations is:

a. World Health Organization

b. American Medical Association

c. The Joint Commission

d. National Committee for Quality Assurance

c. The Joint Commission

The Joint Commission is the largest accrediting body/agency.

a. World Health Organization - is a goverment agency that leads and champions global efforts to give everyone, everywhere an equal chance to live a healthy life.

b. AMA - is a professional association that provides education for physicians and promotes the art and science of medicine and the betterment of public health.

d. National Committee for Quality Assurance - is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations and manages the evolution of HEDIS®, the performance measurement tool used by more than 90 percent of the nation's health plans.

Fill in the blank:

The Health ____ _______ Administration (HCFA) encouraged the use of statistical sampling to promote consistency in interpretation and establish FCA liability for claims submitted under Medicare

"Care Financing"

See HFCA Ruling No. 86-1 (Feb. 20, 1986).

One of the most important foundations of your compliance program is:

a. The Compliance Policy Manual

b. The Organization Code of Conduct

c. The non-retaliation policy

d. Adequate staffing and information systems

b. The Organization Code of Conduct

A number of standard components are usually included in codes of conduct, the most common components are the following EXCEPT:

a. Non-retaliation promise

b. Auditing status

c. Organization's values

d. Details on reporting misconduct

EXCEPT: b. Auditing status

Which is not one of the seven fundamental elements of an effective compliance program?

a. Implementing written policies, procedures, and standards of conduct.

b. Conducting effective training and education.

c. Developing policy guidance summaries.

d. Responding promptly to detected offenses and undertaking corrective action.

This is not a core element of the program.

c. Developing policy guidance summaries.

What are the three things an effective compliance program can bring to your organization?

(OQC: Operations, Quality and Costs)

Enhance your organization's operations,

improve quality of patient care and

reduce overall costs

What are the benefits to a Compliance Program?

1. Commitment to Code of Conduct.

2. Prevent, detect, and correct unethical behaviors.

3. Minimizes financial losses

4. Encourages employees to report compliance problems/issues

What are the two primary objectives of a Board of Directors (BOD)?

1. Duty of Care decision making

2. Oversight function (BOD can delegate to CEO)

What are the two primary focus areas of a Board of Directors (BOD) in compliance?

1 - structural (need to understand compliance program SOW)

2 - operational (need to understand compliance program needs to operate)

What does Duty of Care mean for BOD?

1. act in good faith

2. level of care a prudent person would (avoid negligence)

3. protect welfare of organization, act in a manner that's best for all

What are the three roles of a board member?

1.Compliance oversight.

2.Structuring your compliance program

3.Evaluating effectiveness of the compliance standards and processes.

When creating and implementing a compliance plan, the compliance officer should have:

A. no approval

B. board approval and resolution

C. patient approval

D. legal approval

B. board approval and resolution

What can an effective compliance program do?

Enhance your organizations operations,

improve quality of patient care, and

reduce overall costs.

True or False - A good compliance program will identify problems from time to time, if it doesn't, that's a sign that what you're doing is NOT effective

TRUE

What can providers review that will help them understand the compliance requirements of a clinical lab?

a. Laboratory Provider Handbook

b. OIG's Clinical Lab Guidance

c. OIG Developing an Effective Compliance Program

d. Physician Desk Reference

b. OIG's Clinical Lab Guidance

The OIG Clinical Lab Guidance provides pertinent information on effective compliance and risk areas for laboratories.

Note: practice question from AAPC CPCO Ch3

Any laboratory performing testing on specimens derived from a human being for purposes of providing diagnosis, prevention, treatment, or assessment of health, regardless of whether they participate in Medicare, must:

a. Participate in a quality assurance program

b. Maintain adequate hours of operation for the underserved community

c. Enroll in the CLIA program

d. Have a certificate of compliance

c. Enroll in the CLIA program

Note: practice question from AAPC CPCO Ch6

If I'm only doing blood draws, do I need a CLIA number?

a. No, a CLIA number is not required if the facility only collects specimens and performs no testing.

b. No, a CLIA number is not required if the facility only collects specimens and performs minor testing.

c. Yes, a CLIA number is required if the facility only collects specimens, even if they perform no testing.

d. Yes, a Medicare-participating provider that only collects specimens requires a CLIA number.

a. No, a CLIA number is not required if the facility only collects specimens and performs no testing.

Note: practice question from AAPC CPCO Ch6

Which certificate is issued to a laboratory that enables the entity to conduct moderate- to high-complexity laboratory testing until the entity is determined by survey to comply with the CLIA regulations

a. Certificate of Compliance

b. Certificate for Provider-performed Microscopy procedures

c. Certificate of Registration

d. Certificate of Waiver

c. Certificate of Registration.

Enables the entity to conduct moderate-to high-complexity laboratory

testing until the entity is determined by survey to be in compliance with the CLIA regulations.

Note: practice question from AAPC CPCO Ch6

Seven basic elements for a fundamental compliance program as per HCCA CHC exam?

1. Standards and Written Policies & Procedures

2. Compliance Program Admin (CO and Board oversight)

3. Effective Education &Training

4. Screening and Evaluation (Employees, Physicians, Vendors)

5. Communication, Edu & Training

6. Auditing & Monitoring, Internal Reporting System

7. Discipline for Non-Compliance

8. Investigation and Remedial Measures

True or False - The OIG requests that you post on your website whether or not the PHRMA CODE is followed

TRUE

True or False:

Regarding Attorney-Client Privilege, the procedure called "Upjohn warning," in which a company's lawyer explains that the lawyer represents the company and not the individual employee with whom the lawyer is dealing.

TRUE

The Upjohn Co. v. United States case (1981), a Supreme Court case that gave rise to the procedure called "Upjohn warning," in which a company's lawyer explains that the lawyer represents the company and not the individual employee with whom the lawyer is dealing. In other words, communications between company counsel and employees of the company are privileged, but the privilege is owned by the company and not the individual employee.

The Court made clear that the corporate attorney-client privilege applied to the company.

Related to Legal Doctrines for Protection from Disclosure to protect certain documents during the course of discovery.

What is the work product doctrine?

a. Ensures that attorney documentation is accessible to the hospital.

b. Ensures that attorney documentation is accessible to the OIG.

c. Protects attorney documents that were prepared for litigation purposes.

d. Allows the hospital to protect documents sent to the attorney.

c. Protects attorney documents that were prepared for litigation purposes.

Differs from attorney-client privilege (ACP) in that it protects only documents from discovery including interviews, memos, correspondence, notes and briefs, which evidence "mental impressions, conclusions, opinions or legal theories of any attorney.

Documents must have been prepared in anticipation of litigation or in anticipation of a disclosure to the government.

When should counsel be involved during an internal investigation?

a. If corporation may have to disclose inappropriate conduct and take remedial action.

b. If there is an inadvertent billing error.

c. If there is a question about the training program.

d. If there is fraudulent behavior that the CCO wants to cover up.

a. If corporation may have to disclose inappropriate conduct and take remedial action.

True or False:

Root cause analysis is a high priority among federal law enforcement and regulatory agencies when it comes to investigations and risk assessments. For example, in a compliance investigation, investigators gather evidence either to support or refute specific allegations, but the investigation itself does not assess blame. That is the point in which root cause analysis should follow to determine how the compliance failure occurred or was allowed to happen.

TRUE

Root cause analysis is performed after an incident occurs, so in a sense, it could be considered a reactive activity, unlike a risk assessment, which is inherently proactive.

The purpose of root cause analysis is to prevent future recurrences of the problem.

Ref. 2022/23 HCCA Complete Healthcare Compliance Manual

Which of the following agencies indicate a self-evaluation after discovery of potentially fraudulent acts?

a. CMS

b. OIG

c. OCR

d. OSHA

b. OIG

Fill in the blank:

The Healthcare Fraud and Abuse Control (HFCA) program requires ___ and ___ to coordinate federal, state, and local health care law enforcement activities, provide guidance to providers on fraudulent practices, and establish a national data bank to receive and report final adverse actions against providers.

HHS-OIG and DOJ

Health Care Financing Administration (HCFA) encouraged one of the following to promote consistency in interpretation of claims?

a. Education

b. Reporting

c. Discipline

d. Statistical sampling

d. Statistical sampling

Related to Corporate Integrity Agreements with the government, what is an IRO and what are the details of how it works? Choose 2 answers.

a. Independent Reorganization Operation.

b. They do the auditing required by a CIA.

c. The OIG hires them.

d. They need to be fair and unbiased and can't have a financial relationship with the hospital.

b. They do the auditing required by a CIA.

d. They need to be fair and unbiased and can't have a financial relationship with the hospital.

Explanation: IROs need to meet criteria and follow the AICPA and SEC guidance (unbiased judgement, honest neutrality, and demonstrate independence among other requirements)

The IRO is conducting a Claim Review for a hospital under a CIA and discovers that there is a discrepancy between the dollar difference between the amount that was reimbursed and the amount that should have been reimbursed when conducting a Discovery Sample. Which of the following is false:

a. The dollar difference resulted in an overpayment. And when converted to percentage, the resulting calculation is the error rate

b. The net financial error rate calculated was under 10%, no need to conduct a Full Sample

c. If the net financial error rate of the Discovery Sample is below 5%, the review is complete

d. A and C

b. The net financial error rate calculated was under 10%, no need to conduct a Full Sample

According to the OIG, a Full Sample size is only required if the net financial error rate of the Discovery Sample equals or exceeds 5%.

https://oig.hhs.gov/faqs/corporate-integrity-agreements-faq.asp

Which Act created the Medicaid Integrity Program to ensure that Medicaid payments are for covered services that were actually provided, properly billed and documented; and requires that entities receiving more than $5 MIL in annual Medicaid payments establish written policies and educate employees on the FCA and whistleblower protections to prevent and detect Fraud, Waste and Abuse.

The Deficit Reduction Act (DRA) of 2005 created the Medicaid Integrity Program (MIP) under Section 1936 of the Social Security Act.

If you find you actually are doing something wrong, corrective actions should be put in place. For instance, if you identified an overpayment, your FIRST action is to refund to the Fiscal Intermediary. If you suspect the possibility of serious wrongdoing that may affect your organization's reputation, your FIRST action is to contact legal/attorney to assess if attorney-client privilege needs to be attached. If you identified that certain employees are not properly being disciplined for misconduct, your FIRST action is to work with _________ and recommend that discipline should be fair, equitable and consistent.

HR/Human Resources

Examples of current Compliance activities in many organizations

• Equal Employment Opportunity Commission (EEOC)

• Employee Retirement Income Security Act (ERISA)

• Wage and Hour Rule

• Occupational Safety and health Administration (OSHA)

• Nuclear Regulatory Commission

• Joint Commission on Accreditation of Healthcare Organization (JCAHO)

• Research compliance

What is a benefit of a contemporaneous review?

a. Can provide a chance to do a self-disclosure of prior billing errors

b. Helps with creating a code of ethics

c. Can correct a problem before it grows to become a serious issue

d. Allows employees to submit anonymous reports of fraud

c. Can correct a problem before it grows to become a serious issue.

How does Medicaid work? Select 2

a. State administered

b. Federally administered

c. State monitored

d. Federally monitored

a. State administered (via SURS and MFCUs);

d. Federally monitored (OIG oversights each state MFCU's operational costs)

https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/

What can a provider do if they are unhappy with an informal review by the state Medicaid Program/SUR unit?

a. Dispute the informal review with the SUR.

b. Request an administrative hearing.

c. Request that the informal review be made into more understandable education.

d. Request that the Fiscal Intermediary take back the repayment.

b. Request an administrative hearing

A compliance program at its most basic level would be: (think of the 1st CP element)

A set of internal policies and procedures that you put into place to help your organization comply with the law

What is a compliance program?

• Ongoing process, part of fabric of organization, commitment to ethical way of conducting business

• Prevention, Detection, Collaboration, and Enforcement

• System of policies and procedures developed to assure compliance with and conformity to all applicable federal and state laws governing organization

Health care Fraud is key priority in the Justice Department, and an effective _________ program safeguards the organization's legal responsibility to abide by applicable laws and regulations

Compliance (program)

Benefits of Compliance Program

• Safeguards organization legal responsibility to abide by applicable laws and regulations

• Demonstrate organization's commitment to good corporate conduct

• Identify and prevent criminal and unethical conduct

• Create a centrilized source of info on healthcare regulations

• Develop a methodology to encourage employees to report potential problem

• Develop procedures that allow the prompt and through investigation of alleged misconduct

• Initiate immediate and appropriate corrective action

• Reduce organization remedies, such as program exclusion

Why Compliance Programs are Essential

• Help reducing threat of qui tam or whisthelblower lawsuits

• Prevent exlusion from government program

• Probation and court imposed programs

• Government designated programs

• Payback to fiscal intermediaries or carriers may result in audited services

HCCA 2 components of a compliance program

1. structural component (OIG 7 elements to create the framework - "nuts and bolts")

2. substantive component (applicable laws and regulations)

This Act mandates compliance programs for Medicare, Medicaid and Children's Health Insurance Program (CHIP) providers

The Affordable Care Act (ACA)

Section 6401 of the ACA provides that a "provider of medical or other items or services or supplier within a particular industry sector or category" shall establish a compliance program as a condition of enrollment in Medicare, Medicaid, or the Children's Health Insurance Program (CHIP)

Also ref: 42 CRF 422.503(b)(4)(vi) and 42 CFR 423.504(b)(4)(vi)