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CHC RANDOM STUDY QUESTIONS AND VERIFIED ANSWERS
"An Organization identifies a potential issue when reviewing personal services and management contracts. Which of the following should the compliance professional consider in analyzing the issue? a. Deficit Reduction Act (DRA) b. Conditions of Participation (CoP) c. IRS tax-exempt guidelines
d. Anti-Kickback (AKS) Safe Harbors - CORRECT ANSWER d. Anti-Kickback (AKS) Safe Harbors"
"A hotline caller states the coding department was instructed to code based on LCD requirements regardless of medical record information. Which of the following should be the compliance professional's FIRST action? a. direct the coding supervisor to follow the applicable policy b. incorporate the coding issue into next year's risk assessment c. design a review to find facts and circumstances related to the compliant
d. engage outside counsel to protect the underlying facts from discovery - CORRECT ANSWER
c. design a review to find facts and circumstances related to the compliant" "A compliance professional identified an issue with medical necessity. The compliance professional should collaborate with the: a. case manager b. billing clerk c. documentation specialist
d. patient account representative - CORRECT ANSWER a. case manager"
"When non-compliance is substantiated, disciplinary action should be administered a. within 30 days b. if intent is proven c. in a consistent manner
d. after completion of corrective action - CORRECT ANSWER c. in a consistent manner"
"Incentive programs based on employee performance may be tied to increases in a. the case mix index b. CPT/DRG codes c. patient referrals
d. patient satisfaction - CORRECT ANSWER d. patient satisfaction"
"A preliminary investigation identified payments to physicians for medical directorship without written contracts. Which of the following should be the compliance professional's NEXT step? a. determine if Medicare payments were received b. initiate a voluntary disclosure c. provide education to contracting office
d. refund payments to the contractors - CORRECT ANSWER a. determine if Medicare
payments were received" "In an investigation, the MOST important responsibility of the compliance professional is to a. personally conduct all investigations b. assure independence in investigations c. set the scope and sample size related to investigations
d. remain within the budget for investigations - CORRECT ANSWER c. set the scope and
sample size related to investigations" "Training is scheduled for employees to learn about cost reporting risks. This type of training is an example of a. online training b. general training c. focused training
d. orientation training - CORRECT ANSWER c. focused training"
"Which of the following are MOST relevant in evaluating the effectiveness of a compliance training program?
- percent of target audience that has attended
- whether the training is computer-based or classroom-based
- whether training adequately addresses areas of concern
- improvement shown in pre- and post-training quizzes A. 1, 2, 3 only B. 1, 2, 4 only C. 1, 3, 4 only
D. 2, 3, 4 only - CORRECT ANSWER C. 1, 3, 4 only"
"Quitam actions enable any person to bring forth an action to the a. employer, based upon original knowledge b. employer, based upon public information
"Corporate Integrity Agreements (CIA) are negotiated primarily between the: a. US attorneys and the hospital b. DOJ and the provider c. Federal Sentencing Commission and the organization
d. OIG and the healthcare entity - CORRECT ANSWER d. OIG and the healthcare entity"
“Compliance means (Compliance Program) - CORRECT ANSWER Adherence to laws and
regulations, as well as principles of ethical conduct" "OIG urges the ____________ to assist in the implementation of the compliance program and serves as advisors. A. Board B. CEO C. Compliance Committee
D. Quality Committee - CORRECT ANSWER C. Compliance Committee"
"A compliance professional is reviewing the policies and procedures for exclusion verifications. The policy does not state frequency of exclusion verifications. How frequent should exclusion verifications be performed? a. Annually b. Bi-annually c. Monthly
d. Semi-annually - CORRECT ANSWER c. monthly (as recommended by OIG to avoid risk)"
"OIG can impose mandatory exclusion for a minimum of..? - CORRECT ANSWER 5 years"
"True or False:
An excluded individual is automatically reinstated at the end of an exclusion term - CORRECT
ANSWER FALSE - An excluded individual must apply for reinstatement at the end of their
exclusion term" "A privacy professional is reviewing a program for an academic medical center that include a faculty group practice, hospital, student health center, and self-funded group health plan. The privacy professional should evaluate if the program has notices for: a. GINA b. FMLA c. HIPAA
d. FISMA - CORRECT ANSWER c. HIPAA"
"A health system implemented an EHR in 55 clinics. The privacy professional is told employees are inconsistently interpreting the policy addressing employee access to EHR. Which of the following is the privacy professional's BEST strategy? a. Collaborate with HR to ensure appropriate discipline b. Perform an audit under Attorney-Client Privilege c. Conduct surveys of clinic employees concerns
d. Audit a random sampling of clinics across the organization - CORRECT ANSWER c. Conduct
surveys of clinic employees concerns"
"What are the 2 types of OIG exclusions? - CORRECT ANSWER Mandatory and Permissive.
See definitions: https://oig.hhs.gov/exclusions/background.asp"
"Concurrent Audit - CORRECT ANSWER Real time - Ongoing review/inspection of records,
policies and procedures. More difficult to execute but best way to change behavior. Identify and address problems as they arise - Example: Auditing claims before claims are billed"
"What is DRG Creep - CORRECT ANSWER Using a Diagnosis Related Group (DRG) code that
provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient." "In Compliance Auditing & Monitoring, Contemporaneous Reviews: a. Involves matter that either have not yet been billed by provider or have not yet been paid by the third party payor b. Appropriate to determine an initial baseline view of a particular billing practice or activity c. Can uncover existence of past problems e. All of the above
f. A and B only - CORRECT ANSWER e. All of the above"
"Retrospective Audit - CORRECT ANSWER Baseline assessment of where you are at a period of
time in the past Snapshot or Laundry list of things needed to be fixed Need to know a milestone to go back to in time (e.g.; published financial statements, historical audit)"
"Retrospective vs Concurrent Audit can be characterized by... - CORRECT ANSWER
Retrospective milestone to go back to in system, you know the sample unit from system. Concurrent any time up to the final, real time"
the facts that underlie these communications. For instance, a client provides an attorney with a host of facts when communicating, but the privilege does not protect these facts from disclosure
- only the communications themselves."
"EEOC - CORRECT ANSWER Equal Employment Opportunity Commission of 1964.
Definition: Agency created in 1964 to end discrimination based on race, religion, sex, or national origin in employment"
"ERISA - CORRECT ANSWER Employee Retirement Income Security Act of 1974
Definition: Federal act that exempts self-insured health plans from state laws governing health insurance and requires health plans to provide certain information to enrollees"
"HITECH stands for: - CORRECT ANSWER Health Information Technology for Economic and
Clinical Health. Act was signed into law in February 2009 under ARRA"
"Coding for a higher level than the documentation warrants. This is known as: - CORRECT
ANSWER Upcoding"
"The illegal practice of submitting claims individually in order to maximize reimbursement for various tests or procedures which are required to be billed together. The government initiative
investigating this issue is Project Bad Bundle. This is known as: - CORRECT ANSWER
Unbundling"
"A covered entity may use or disclose PHI for TPO...what does TPO stand for - CORRECT
ANSWER Treatment,
Payment, Health Care Operations"
"Few other examples for use or disclosure of PHI other that TPO: - CORRECT ANSWER Public
health interest, research, serious threat, organ/tissue donation decedents (deceased person) information, worker's compensation insurers." "True or False A vendor that stores encrypted copies of files from a CE is not a Business Associate of that CE
because the ePHI is unreadable, unusable, and indecipherable. - CORRECT ANSWER FALSE -
The vendor is a Business Associate as it is maintaining (through its storage functions) the encrypted ePHI." "True or False Covered Entities and their Business Associates must comply with all of the Security and Privacy
Rules - CORRECT ANSWER FALSE - Business Associates are not required to comply with all of
the Privacy Rules."
"What is a Business Associate (BA)? What do they do in healthcare? - CORRECT ANSWER BA is
an entity that performs/assist Covered Entities in activities involving the use/disclosure of individually identifiable health information (IHI) on behalf of a Covered Entity or provides services such as legal, actuarial, accounting, data aggregation, or financial services for a covered entity"
"Designated Record Set (DRS) - includes: - CORRECT ANSWER Group of records maintained by
or for a Covered Entity that comprises the following:
- medical/billings records
- enrollment/payment/claims adjudication/case management by health plan
- other records used by or for covered entity to make decisions about individuals"
"Designated Record Set (DRS) - records excluded from DRS: - CORRECT ANSWER
Administrative data (audit trails, appointment schedules, that don't imbed PHI). Incident reports. Quality Assurance Data. Statistical reports."
"1984 Sentencing Reform Act - CORRECT ANSWER Designed to correct inequities in deferral
sentences. Includes the Federal Sentencing Guidelines that include guidance for assessing fines and detailed method for calculation of a "culpability score.""
"5 most important federal fraud and abuse laws - CORRECT ANSWER FCA, AKS, Stark Law,
CMPL, and Exclusion Authorities"
"Why is Caremark International Derivative Litigation important in Corporate Compliance? -
CORRECT ANSWER The 1996 U.S. Civil settlement of Caremark International, Inc. Decision
established Corporate directors breached their oversight duty by failing to adequately supervise their employees when they knew/should've known a violation of law was occurring. Ref: 698 A.2d 959 (Del. Ch. 1996). Org entered into a 5-year imposed CIA.
- Felony convictions for other health-care related fraud, theft, or other financial misconduct;
- Felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances" "Proof of intent is not required for: a. false claims act b. antikickback statute c. stark law
d. affordable care act - CORRECT ANSWER c. Stark Law"
"Sarbanes-Oxley Act of 2002 or SOX Act - CORRECT ANSWER Federal law that established
sweeping auditing and financial regulations for public companies. Lawmakers created the legislation to help protect shareholders, employees and the public from accounting errors and fraudulent financial practices. It was enacted in response to a series of high-profile financial scandals that occurred in the early 2000s (i.e. Enron). Learn more: https://www.congress.gov/bill/107th-congress/house-bill/3763"
"The Stark Law is also commonly referred to as - CORRECT ANSWER Physician Self-Referral
Law" "TRUE or FALSE: STARK indicates no Medicare payments may be made for DHS referred by the physician, and the
Entity must refund all money collected for DHS referred by the physician - CORRECT ANSWER
TRUE
In other words, Stark law bans physicians from referring 10 designated health care services to any entity with which physician has a financial relationship."
"What is False Claims Act? - CORRECT ANSWER Laws for the government to enforce federal
fraud and abuse prohibitions. Prohibits anyone from knowingly submitting false/fraudulent claims"
"What is Fiscal Intermediary (FC) - CORRECT ANSWER It refers to an entity or a private
company that has a contract with the center for Medicare and Medicaid services (CMS) to determine and to pay part A and some part B bills such as bills from hospitals, on a cost basis and to perform other related functions"
"What is Physician Payment Sunshine Act? - CORRECT ANSWER Requires drug/device
manufacturers to disclose to government anything of value provided to physicians (report quarterly). Applies to companies with gross revenue over $100 MIL"
"What is the anti-kickback statute? - CORRECT ANSWER Prohibits any knowing and willful
conduct involving solicitation, receipt, offer, or payment of any kind of remuneration in return for referring an individual or for recommending or arranging the purchase, lease, or ordering of an item or services that may be wholly or partially paid for under a federal health care program."
"What is Attestation? - CORRECT ANSWER It's an affirmation signed by signature that the
action outlined has been accomplished" "Which of the following does EMTALA require? a. Appropriate signage in all hospital waiting areas b. Acute patient to be stabilized before being transferred to another hospital c. Attestation by the treating physician or other appropriate licensed independent personnel that the patient is stable d. Receiving hospital must have resources available and appropriate licensed personnel to treat the patient e. All of the above f. B and C
g. A, C, and D - CORRECT ANSWER e. All of the above
http://www.emtala.com/faq.htm"
"Which of the Fraud and Abuse laws contains the whistleblower provision? - CORRECT
ANSWER False Claims Act (FCA)"
"Examples of "outliers" that OIG might identify in certain hospital relationships or arrangements with greatest risk of non-compliance: a. audit processes that includes e-visits, interviews, trend analysis, etc. b. medical office building leases consistent with fair market value c. large and inconsistent payments made to physicians without a written contract
d. none of the above - CORRECT ANSWER c. large and inconsistent payments made to
physicians without a written contract" "The PhRMA Code prohibits which of the following: a. Pharmaceutical companies that bring free lunches to a healthcare organization weekly to promote the use of their product
"In development of the annual work plan, physician contract compliance was prioritized as a high- risk area. When the compliance professional followed up with management, it appeared that the monitoring identified for this area was never put into place. Which of the following should be the compliance professional's FIRST step? a. Develop a corrective action plan b. Identify a statistically valid sample c. Conduct a probe sample
d. Notify legal counsel - CORRECT ANSWER c. Conduct a probe sample"
"Which of the following is the BEST question to include in an employee exit interview? a. Why are you leaving your job? b. Did you ever observe anything that made you feel uncomfortable? c. How many times did you use the compliance hotline?
d. Do you think your patients knew about the hotline? - CORRECT ANSWER b. Did you ever
observe anything that made you feel uncomfortable?" "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 - CORRECT ANSWER a.
financial error rate exceeds 5% with a refund to occur within 60 days" "A compliance professional discovers non-compliance with a regulation. Which of the following the compliance professional do FIRST? a. implement disciplinary actions b. conduct a baseline audit c. include it in the annual work plan
d. develop a risk specific education plan - CORRECT ANSWER b. conduct a baseline audit"
"A record retention policy must be based on a. AHIMA requirements b. applicable state laws c. state insurance commissioner's requirements
d. applicable electronic health record constraints - CORRECT ANSWER b. applicable state
laws" "Under HIPAA, a covered entity is required to disclose Protected Health Information (PHI) when: a. the disclosure is requested by the police department b. a subpoena signed by an attorney is received c. the disclosure is required by medical staff bylaws
d. the Secretary of DHHS requests the information - CORRECT ANSWER d. the Secretary of
DHHS requests the information" "The annual OIG work plan is a document that outlines the OIG's annual: a. staffing needs b. budget plans c. investigation ideas
d. education agenda - CORRECT ANSWER c. investigation ideas"
"A compliance professional conducts an investigation into allegations of physicians and nurses taking pictures of injuries and posting them on a social network. It is confirmed that the two physicians and a nurse have engaged in this behavior. Which of the following is the compliance professional's and HR director's BEST action? a. review and adhere to the organization's disciplinary policy b. revoke the physician's hospital privileges, and terminate nurse c. report the incident to the Peer Review Committee and the nursing board
d. notify the board of directors, and act according to their recommendations - CORRECT
ANSWER a. review and adhere to the organization's disciplinary policy"
"A hospital medical staff office is conducting its monthly review of the Excluded Parties List System (EPLS). The compliance officer is called by the manager of the medical staff office and informed that Dr. Smith, a surgeon who took call 5 times last month for the Emergency Department, was excluded on a date prior to those dates when the surgeon took call. In other words, the effective date of the exclusion involving the surgeon was 4/1/2019 and the surgeon took call and provided surgical services to patients in the ED on 4/13/19, 4/20/19, and 4/27/2019. What is the NEXT action the compliance officer should do? a. Contact the ED and make sure that the involved surgeon is removed from taking any more on call shifts. b. Have the medical office check if the surgeon is listed on other exclusion lists. c. Contact legal counsel to alert of the need to pay back reimbursement received for services
provided by an excluded ind - CORRECT ANSWER b. Have the medical office check if the
surgeon is listed on other exclusion lists" "Under the US Federal Sentencing Guidelines, there is an expectation that effective compliance programs include due diligence in discretionary authority and hiring. Which of the following is MOST important process to include? a. Periodic background checks b. Drug Testing c. Monthly exclusion verifications through OIG database
d. Monthly exclusion verifications through SAMS GSA Exclusion database - CORRECT ANSWER
d. Monthly exclusion verifications through SAMS GSA Exclusion database.
"What is HIPAA? - CORRECT ANSWER Comprehensive legislation that protects health
information, ensure access to health coverage for those who change jobs or temporarily out of work, and provides funding to DOJ and FBI for Medicare fraud investigations"
"What is the difference between HIPAA Privacy and Security? - CORRECT ANSWER Privacy -
covers all forms of PHI (ePHI, written, oral). Security - covers ePHI only" "An HHS/OIG nationwide review of compliance with rules governing physicians at teaching hospitals. Records were reviewed to determine adequate physician involvement in patient care according to IL373, the Medicare rule that dictates that an attending physician must be present when supervising an intern or resident in order to bill for the care provided by the intern or the
resident. - CORRECT ANSWER Physicians at a Teaching Hospital (PATH)"
"Balance Budget Act of 1997 (the 3-strike rule) - CORRECT ANSWER Legislation containing
major reform of the Medicare and Medicaid programs especially in the areas of home health and patient transfers. It also mandated permanent exclusion from participation in federally funded health care programs of those convicted of three health care-related crimes"
"Caremark International Derivative Litigation - CORRECT ANSWER A civil action concerning a
director's duty of care. Caremark directors breached their duty of care by failing to adequately supervise their employees when they knew/should've known a violation of law was occurring. Ref: 698 A.2d 959 (Del. Ch. 1996) Also known as the "Caremark Duty" - makes the board responsible for implementation of a system to gather information on the company's efforts to prevent and detect fraud and abuse."
"False Claim Act (FCA) - CORRECT ANSWER • Empowers government to investigate and bring
civil action in fraud case. Implemented during Civil War to curb war time price gouging.
- Also allow private citizen to bring civil actions against an organization in the name of United States. This action provided significant incentive for the private citizen to come forward. This action is better known as Qui Tam, whistle blower. Sometimes called Lincoln's Law as it was implemented during the Civil War to protect against price gouging to the military."
"General Services Administration (GSA) - CORRECT ANSWER Government agency that was
established in 1949. GSA is the purchasing department of the U.S. government and lists contracts or schedules that potential vendors can bid on to get government business. In other words, GSA manages the gov's property and records." "Organizations have the opportunity to reduce their culpability in accordance with the Federal Sentencing Guidelines by
A. establishing mandatory audits. B. effectively dealing with any offense after it has occurred. C. developing a code of conduct and educating senior management.
D. voluntarily disclosing overpayments. - CORRECT ANSWER B. effectively dealing with any
offense after it has occurred. (review FSG capability factor https://www.ussc.gov/guidelines/2015-guidelines-manual/2015- chapter-8)" "The primary purpose of a privacy exit interview is to: a. Meet HITECH requirements b. Prevent whistleblower lawsuits c. Evaluate for rehire
d. Determine the appropriate discipline - CORRECT ANSWER b. Prevent whistleblower
lawsuits"
