han434 test 1

what is corporate complaince?

following all the rules

doing the right thing

about making good ethical decisions

what is a culture of compliance?

how to mandate policies

putting the legs to the program

Medicare is a ____ health insurance program

federal

Medicare is a program for who?

americans over the age of 65 who receive benefits from the SSA and the railroad retirement baord

People under 65 may qualify for Medicare if they have

long term disabilities or end stage renal disease

Medicare Part A

hospital coverage

this covers SNF and home health care that are required after hospitalization

Medicare Part B

outpatient coverage

physician services

Medicare Part C

medicare advantage plans

private insurance companies contract with medicare to bundle services from A, B and can include D into one insurance plan

Medicare part D

beneficiaries have the option to purchase Rx coverage

what is title 18 of the SSA?

MediCARE

what is title 19 of the SSA?

MedicAID

Title 19 and 19 of the SSA gave the state the option of receiving federal funding to provide health care services to_______?

low income families

pregnant women

the blind

individuals with disabilities

who decides who is eligible for medicAID?

the states

Medicaid

the federal funding to the states

The patient protect and affordable care act was signed in?

2010

The ACA prohibits what?

it prohibits health insurance companies from denying or charging more based on the individual’s health status

The ACA established what?

the healthcare market place

what is the Health care market place?

a single place where consumers can apply and enroll in private health care insurance plans

The CMS developed the ______ and the _____ that health care organizations must meet health and safety standards to qualify as a medicare/ medicaid provider

Cfc and CoP

The OIG fights against what?

Fraud waste and abuse

the OIG works to improve what?

the efficiency of the DHHS programs

what is the largest DHHS program?

Medicare/Medicaid

The OIG conducts these activities:

audits

investigations

evaluation

educates the public about fraudulent schemes

recommend policies to protect the DHHS programs

assists with the development of criminal, civil, and administrative cases

OMIG is a program integrity agency established in 2006 to ___?

detect and prevent fraudulent and wasteful spending in the Medicaid program

The OMIG conducts:

Inspections, audits, training

The OMIG requires Healthcare organizations to have what?

corporate compliance program

Civil penalty of _______ as adjusted by the federal civil penalties adjustment act of 1990

not less than 5K but not more than 10K

civil penalties of not less than 5K but not more than 10K plus___________________?

not more than 3x the amount of damages which the government sustains because of the act of that person

reduced damages

the court may asses NOT LESS THAN 2X the amount of damages which the government sustains because of the act of the person

the US sentencing commission promulgated the federal sentencing guidelines for organization defendants for what?

felony

class A misdemeanor offenses

the federal sentencing guidelines established standards for the US government to respond to what?

misconduct occurring with organizations

prior to the federal sentencing guidelines the government inconsistently did what?

investigate and punish organizations for misconduct

the federal sentencing guidelines tie an organization’s penalties to its effort to ___________?

establish a strong compliance program

1 of 3 sanctions

under the federal sentencing guideline

Ordering the organization to remedy the harm from the offense

* restitution
* correct policies, procedures and practices

2 of 3 sanctions

under the federal sentencing guidelines

Providing oversight of the organization through probation

* unannounced examinations of company’s records
* ongoing employee interviews

3 of 3 sanction under the federal sentencing guidelines

penalizing the organization on the basis of seriousness of _________

the offenses

culpability score

what is culpability score?

a standard mechanism for determining the
fine based on an assessment of the Compliance Program

an effective compliance program:

* Exercises due diligence to prevent and detect criminal conduct


* Promotes an organizational culture that encourages ethical conduct and a commitment to compliance with the law

the federal sentencing guidelines require how many elements for an effective compliance program?

\

7

How many elements does the OMIG require for it to be an effective compliance program?

8

(whistleblower protections)

in 2009 this state became the first state to require health care organizations to demonstrate that they have an effective compliance program through an annual certification

New York

The eight elements to an effective compliance program

1. Compliance Officer and Compliance Committee
2. Compliance Standards and Procedures
3. Communication and Reporting
4. Compliance Training
5. Monitoring and Auditing
6. Enforcement of Standards
7. Investigation and Remediation
8. Whistleblower Protections (Required by the OMIG)

the compliance officer shall directly report to the _____

chief executive officer

The compliance officer shall make_____

periodic (at least quarterly) reports regarding compliance matters in person to the CEO

who maintains the minutes of the meeting?

the compliance officer

The Compliance Officer shall chair a Compliance Committee that
includes

other members of senior management such as billing, clinical, human resources, audit, and operations

Compliance policies and procedures are required to describe

expectations and provide guidance to members of its workforce and
affiliates to address and communicate compliance issues.

Internal control, as defined by the Committee of Sponsoring Organizations
of the Treadway Commission (COSO), is:

a process,
▪ effected by an entity’s board of directors, management and other personnel,
▪ designed to provide reasonable assurance regarding the achievement of
objectives in the following categories:
o effectiveness and efficiency of operations,
o reliability of financial reporting, and
o compliance with applicable laws and regulations

All members of the workforce are required to participate in Compliance Training and Education periodically, the industry standard is

at least once a year

training records must be maintained, including:

training materials

Training must be conducted in a manner tailored to:

▪ Size of the audience
▪ Sophistication level of audience
▪ Subject matter
▪ Company history

regrading auditing and monitoring,

Processes must be established to determine the:

o Areas to be audited
o Frequency of audits
o Audit process
o Types of audits

audit findings must be shared with the

management, CEO and board of directors.

Appropriate action must be been taken to

remediate negative audit
findings

What type of audit review is MOST EFFECTIVE?

pre-claim review

risk assessment do what?

identify and prioritize risks

Compliance Program must include mechanisms to enable individuals
to disclose any identified or suspected internal policies, conduct,
practices or procedures that may violate criminal, civil, or
administrative law with respect to federal and state healthcare
programs to

the Compliance Office or other persons who are not in the disclosing individual’s chain of command.

example of compliance helpline communication

anonymous communication

Investigations must be conducted independently and objectively:

by qualified individuals not directly involved or indicated in the reported allegation

investigations must result in

a written report of findings

failure to appropriately discipline individuals who violate compliance
program policies or federal, state and local laws indicates

an inefficient compliance program

deficit reduction act

provide that any entity that receives or makes annual payments under the state plan of at least 5M, as a condition for receiving such payments shall establish written policies about the FCA, have whistleblower protections with respect in preventing and detecting fraud, waste and abuse

when developing an effective compliance program, take into consideration prior history.

Reoccurrence of similar misconduct within an organization may be an
indication that a compliance program is ineffective. Therefore,
compliance programs should be designed

identify and mitigate risk of compliance violations

who assesses the effectiveness of compliance programs?

governing board

HEALTHCARE ORGANIZATIONS ARE REQUIRED TO CERTIFY IN WHAT?

AN EFFECTIVE COMPLIANCE PROGRAM

Article 28 certifies what organizations under the public health law?

hospitals

nursing homes

diagnostic treatment centers

article 36

certifies what organizations under the public health law?

certified home health care

long term home health care program

The deficit reduction act of 2005 requires Healthcare organization that within a 12 month period receive payments from or submit claims to Medicaid of 5M or more to establish what?

a compliance program that includes employee training on the FCA, including training regarding criminal and civil monetary penalties for false claims, whistleblower protections, and the detection and prevention of fraud, waste, and abuse

Prior to certifying the Compliance Program, the Program should be assessed to determine if

* Is it effective?
* Does it include all of the required elements?
* Were the elements completed?
* Are the resources and personnel sufficient

who published guidance for evaluating Corporate Compliance Programs

DOJ

When the U.s is determining

whether to bring charges against an organization or negotiate a plea deal or other agreement, prosecutors should consider is there were:

additional resources invested in the compliance program to
improve the program and internal controls

the 3 questions to consider when Assessing the Effectiveness of the Compliance Program

1. Is the Compliance Program well designed?
2. Is the Compliance Program being applied earnestly and in good faith? Is it
being implemented effectively?
3. Does the Compliance Program work (in practice)?

who exercises overall supervision of the Medicaid program?

NYS department of Health

why is medicaid eligibility verified for each medical visit?

eligibility is date specific

The provider is prohibited from billing the enrollee for medically-necessary inpatient and what?

hospital-based emergency department services.

If the patient does not cooperate by providing the Medicaid information,

the provider may bill the patient as private pay

what program is billed last?

Medicaid is the payer of last resort

Medicaid program is designed to ___________

provide payment for medical care and services only after all other resources available for payment have been exhausted.

MEVs is used to determine what?

if the enrollee has other insurance

qualified medicare beneficiaries (QMB)

elderly and disabled Medicare enrollees with low income and limited assets

The Medicaid Program permits payment toward Medicare premiums, deductibles and coinsurance for certain Medicare Part B services provided to

QMBs

T or F

Medicaid participating providers are not required to render care to all Medicaid enrollees who request care.

True

Medicaid program policies apply to?

Medicaid

Medicaid managed plans

Family Health plus

if a private payment arrangement is made with a Medicaid enrollee, the enrollee must do what?

agree to be seen as a private pay patient

When a private payment arrangement is established, the provider must

not bill medicaid and inform the enrollee that the services may be obtained by another provider

The provider is prohibited from requesting ____ from the enrollee, or their responsible relative, except for applicable Medicaid copayments

any monetary compensation

providers are prohibited from billing Medicaid due to a denied Medicaid claim, except when

the patient was not eligible for medicaid

Providers are prohibited from referring enrollees to a collection agency for unpaid medical bills, except for

medicaid copayments

support for claims in medical billing require what?

Contemporaneous documentation of the provision of services and the furnishing of supplies and equipment.

medicare will not pay for services that are _______

cosmetic purposes

Payment is disallowed for medical care and services: Which are rendered in the absence of authorization from MEVS in accordance with Utilization Threshold requirements. Exceptions to this policy include

instances when a provider uses one of the service authorization exception codes.

unacceptable practices include:

knowingly making a claim for an improper amount or for unfurnished, inappropriate, or unnecessary care, services, or supplies

payments may be suspended or withheld upon____________

notification of unacceptable practices pending the resolution of the charges

who is responsible for monitoring the NYS Medicaid program?

OMIG

audits may be conducted where?

onsite or as desk audits

Managed Care

is a comprehensive and coordinated system of medical and health care service delivery

what is included in managed care?

acute inpatient care and ancillary services. Ancillary services are a wide range of diagnostic and support services to diagnose and treat an illness or injury.

MCOs are contracted by who?

NYS to provide services to enrollees

MCOs are responsible for assuring that enrollees have access to what?

comprehensive range of preventative services, primary care services and specialty services

MCOs may provide services directly or through what?

a network provider