Download Healthcare Compliance Study Guide: Questions and Answers for Professionals and more Exams Medical Records in PDF only on Docsity!
CHC Study Guide Questions With Complete
solutions
Federal Sentencing Guidelines - Culpability Score Aggravating Factors - VERIFIED ANSWER✔✔-1. upper- level employee participates, condones, or ignores offense
- repeat offense
- hinder investigation
- awareness and tolerance of violation is pervasive Federal Sentencing Guidelines - Culpability Score Mitigating Factors - VERIFIED ANSWER✔✔-1. effective compliance program
- reported promptly
- cooperation with investigation
- accept responsibility Federal Sentencing Guidelines - Seven Elements of an Effective Compliance Program - VERIFIED ANSWER✔✔-1. written standards of conduct
- Chief Compliance Officer
- effective education and training
- audits and evaluations to monitor compliance
- reporting processes and procedures for complaints
- appropriate disciplinary mechanisms
- investigation and remediation of systematic problems The only thing worse than not having a policy is... - VERIFIED ANSWER✔✔-...having a policy and not following it. Medicare reimbursement - hospital inpatient codes - VERIFIED ANSWER✔✔-International Classification of Diseases (ICD)
Medicare reimbursement - physician codes - VERIFIED ANSWER✔✔-Current Procedural Technology (CPT) Questions to guide the scope of an internal investigation. - VERIFIED ANSWER✔✔-1. What is the origin of the issue?
- When did the issue originate?
- How far back should the investigation go?
- Can extrapolation of a statistical sample be used? It is in the best interest of the organization to have the board _______. - VERIFIED ANSWER✔✔-...take an active rather than a passive role in compliance. Six tips for saving on future costs of compliance. - VERIFIED ANSWER✔✔-1. embed quality into existing processes
- centralize common processes and controls
- improve human resources infrastructures
- improve information systems processes
- emphasize training
- monitor marketing and compensation Baseline Audit Process - VERIFIED ANSWER✔✔-1. outline the current operational standards
- identify real and potential weaknesses
- offer recommendations Compliance Program - Measures of Effectiveness - VERIFIED ANSWER✔✔-1. staff knowledge
- all 7 elements included
- comparing issues year to year
- tracking and trending complaints
- tracking corrective actions
- reviewing current audits
Unbundling - VERIFIED ANSWER✔✔-submitting bills by piecemeal or in fragmented fashion to maximize reimbursement Outlier - VERIFIED ANSWER✔✔-additional payment for patients with long hospital length of stay Billing and Coding Concerns (*) - VERIFIED ANSWER✔✔-1. coding advice (if not in book - get in writing)
- significant increases in volume (*) (find out why increase)
- hiring external consultants (need BAA, if provide patient care - check OIG sanction list)
- number of auditors for Part B audits
- teaching physicians (*) (physician must be physically present and involved in managing care)
- co-pay waivers (cannot routinely waive)
- record does not support code
- research payments (cannot bill Medicare for costs covered by sponsor)
- disagreements (get 3rd party opinion)
- DOCUMENTATION "Incident To" services - VERIFIED ANSWER✔✔-services commonly furnished in a physician's office by a nurse practitioner in which there is direct physician personal supervision and are billed under the physician's provider number (does not apply in hospital setting) physician must be present to bill () Two-Midnight Rule - VERIFIED ANSWER✔✔-CMS will consider a claim as inpatient if the patient in hospital bed over two midnights 72 Hour Rule/3 Day Window Project () - VERIFIED ANSWER✔✔-all diagnostic outpatient charges and other related outpatient charges within 72 hours prior to an inpatient admission are bundled into inpatient stay reimbursement False Cost Reports (*) - VERIFIED ANSWER✔✔-submission of charges to Medicare which are unrelated to medical care, such as administrative overhead
Credit Balances - Failure to Refund () - VERIFIED ANSWER✔✔-provider has 60 days to refund credit balances () PPS Transfer Project - VERIFIED ANSWER✔✔-PPS transfer of patient (rather than discharge) and receiving payment Advance Beneficiary Notice (ABN) - VERIFIED ANSWER✔✔-a written form that a provider gives to a Medicare beneficiary that informs the beneficiary that Medicare may not pay for an item or service must be provided and signed by patient before services are provided (or provider cannot bill patient if Medicare denies) Medicare Secondary Payer Questionnaire - VERIFIED ANSWER✔✔-used to identify the correct insurance company that must pay health care bills first when Medicare pays second Hospital Outpatient Cardiac Rehabilitation - VERIFIED ANSWER✔✔-physician must be present during treatment DRG Utilization () - VERIFIED ANSWER✔✔-DRG utilization should be reviewed when the number of uses of a particular DRG is outside of the norm or average The three components of Evaluation and Management (E&M) services () - VERIFIED ANSWER✔✔-1. History
- Examination
- Medical Decision Making Evaluation & Management Codes - VERIFIED ANSWER✔✔-1. subset of CPT codes
- privileged providers
- describe complexity of care, place of services, and type of service Types of History or Examination - VERIFIED ANSWER✔✔-1. Problem Focused (CC & brief history)
Medicare Part C (Medicare Advantage) - VERIFIED ANSWER✔✔-Formerly known as Medicare + Choice, government managed care program, must have Part B Medicare Part D - VERIFIED ANSWER✔✔-part of Medicare that reimburses for outpatient prescription drugs Medicare Administrative Contractor (MAC) - VERIFIED ANSWER✔✔-Processes Part A and Part B claims Focused Medical Review (FMR) - VERIFIED ANSWER✔✔-1. determine if documentation supports claim
- reviews guidelines Medicaid - VERIFIED ANSWER✔✔-state health insurance that helps many people who can't afford medical care and pays for some or all of their medical bills 1500 Form - VERIFIED ANSWER✔✔-Non-institutional providers must use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies used to bill Part B claims CMS 1450 or UB-04 - VERIFIED ANSWER✔✔-institutional providers use this form to bill Medicare, Medicaid, CHAMPUS, and most private insurance companies used to bill Part A claims Fiscal Intermediary (FI) - VERIFIED ANSWER✔✔-an insurance company that contracts with CMS to process Medicare Part A claims - replaced by MACs in 2003 a Carrier - VERIFIED ANSWER✔✔-an insurance company that contracts with CMS to process Medicare Part B claims - replaced by MACs in 2003
Centers for Medicare and Medicaid Services (CMS) - VERIFIED ANSWER✔✔-HHS agency that establishes payment policies for providers, conducts research, and evaluates the quality of care provided to beneficiaries Conditions of Participation (COP) - VERIFIED ANSWER✔✔-must be in compliance in order to be reimbursed by CMS CMS Allowable - VERIFIED ANSWER✔✔-how much CMS will reimburse for a particular service or procedure Third Party Carrier - VERIFIED ANSWER✔✔-entity that processes the claims on behalf of CMS Disproportionate Share Hospital (DSH) - VERIFIED ANSWER✔✔-hospital that provides larger amount of care to indigent population CMS provides increased reimbursement for these hospitals to cover cost of uninsured patients Common Working File (CWF) - VERIFIED ANSWER✔✔-information about beneficiaries Return to Provider (RTP) Report - VERIFIED ANSWER✔✔-indication of error in the claim submitted to CMS - must be corrected to receive reimbursement Health Professional Shortage Area - VERIFIED ANSWER✔✔-geographic areas that have been designated as primary medical care shortage areas where physician who furnish medical care are entitled to a Medicare incentive payment Participating Provider/Supplier - VERIFIED ANSWER✔✔-accepts CMS allowable as payment in full for services Certificate of Medical Necessity (*) - VERIFIED ANSWER✔✔-physician statement that services are medically necessary
How is the Compliance Program Addressing Significant Risks? - VERIFIED ANSWER✔✔-1. ensure that we get it right the first time (proactive)
- new business ventures are evaluated for potential risk
- timely response is made to newly developed rules and regulations Why Does the Healthcare Industry Need Compliance Programs? - VERIFIED ANSWER✔✔-1. risks associated with non-compliance have grown dramatically
- board compliance program oversight responsibility is on-going element of the duty of care
- compliance programs are designed to mitigate risks to healthcare organizations in heavily regulated industry Accountable Care Act Compliance Program Requirements (*) - VERIFIED ANSWER✔✔-by end of law everyone that bills federal money must have a compliance program Federal Sentencing Guidelines - General Information - VERIFIED ANSWER✔✔-1. 1991
- chapter 8 - seven elements
- guidelines to help develop compliance program
- give credit if have evidence of the 7 elements Sarbanes/Oxely Act (SOX) - VERIFIED ANSWER✔✔-1. 2000's
- due to Enron
- related to accounting (financial) fraud
- for publicly traded companies
- governance accountability Federal Sentencing Guidelines - 2004 Amendment Compliance Program Recommendations - VERIFIED ANSWER✔✔-1. culture of ethics and compliance
- defining ethics and compliance standards and procedures
- spelling out compliance obligations
- adequate resources
- clarifying employee screening practices
- training as an essential element
- means for anonymous reporting
- ongoing risk assessments (emphasized) Governing Authority (relationship to compliance program) - VERIFIED ANSWER✔✔-1. Board of Directors
- knowledgeable about compliance program with reasonable oversight
- understand program background
- fully engaged in oversight of the compliance program
- adopt a resolution (outline duties, commitment to compliance, reporting requirement)
- responsibility for the plan Developing a Compliance Plan (resources) - VERIFIED ANSWER✔✔-1. OIG Work Plan(*), Advisory Opinions, Fraud Alerts, Settlements
- State Attorney General Actions
- AUSA Settlements/Convictions
- Medicaid Fraud Units (Communications/Investigations)
- Department of Managed Health Care
- Department of Insurance
- Senate Committee Risk Assessment (definition) - VERIFIED ANSWER✔✔-1. identification of risks
- determination of the quantitative or qualitative value of risk related to a concrete situation and a recognized threat (*)
- basis for other elements of the compliance program
- goal is the identification, measurement, and prioritization of likely relevant events or risks that may have a material consequence on ability to meet objectives Why conduct a risk assessment? - VERIFIED ANSWER✔✔-1. Critical activity for the compliance program development and/or ongoing evolution
- establish whether employees trust and use the anonymous reporting mechanism
- ensure that reported incidence are resolved Things that affect risk - VERIFIED ANSWER✔✔-1. organizational ethics
- financial demands
- technology
- competition
- mergers/joint ventures/acquisitions/alliances (*)
- laws/rules/regulations
- unknown (things happening in the organization) Risk Identification - VERIFIED ANSWER✔✔-1. interviews (management/staff)
- document review
- employee surveys
- others? Management Responsibility Related to Risk - VERIFIED ANSWER✔✔-1. identify risk (*)
- implement controls () - avoid risk, transfer risk, accept risk, reduce/mitigate risk It is incumbent upon a health system's ______ to provide ethical leadership to the organization and assure that adequate systems are in place to facilitate ethical and legal conduct. - VERIFIED ANSWER✔✔-corporate officers and managers adequate systems = internal controls () Code of Conduct (elements) - VERIFIED ANSWER✔✔-1. keep it real; values based; avoid legalese
- tailor to organization's culture, ethical attitude, business, and corporate identity (*)
- get input from focus groups, senior executives, etc. (*)
- guidance on seeking help and reporting concerns (non retaliation)
- high-level concepts and key policies
- scenarios and FAQs
- clearly stated expectations
- primary language (watch translations)
- periodically reviewed
- emphasis on compliance with all applicable laws and regulations
- applies to all employees and all representatives
- plain, concise, and relatively short
- signed by employees annually
- training on code provided
- consistently enforced
- outlines discipline for noncompliance Code of Conduct (definition) - VERIFIED ANSWER✔✔-define how to behave Standards and Procedures - VERIFIED ANSWER✔✔-1. Structural (risk assessment methodology, anonymous mechanism and reporting, etc.)
- Substantive (conflict of interest, privacy, etc.)
- integrate and compliment other departmental policies and procedures
- avoid repetition/duplication Training and Communication - VERIFIED ANSWER✔✔-1. mandatory
- needs to be consistent
- effectiveness is seen in behavior Monitoring and Auditing Plan - VERIFIED ANSWER✔✔-1. essential for effectiveness
- based on risk assessment
- scalable to the organization's risks and resources
- effectiveness of corrective actions When to Monitor (*) - VERIFIED ANSWER✔✔-1. when watching compliance becomes part of daily operations
- implementing new rules (*)
- implementing corrective actions
- high risk areas between audits What is Needed for An Effective Compliance Auditing and Monitoring Plan? - VERIFIED ANSWER✔✔-1. understanding of current and applicable business risks and strategies (*) - areas of focus; include audit/monitor plan for each substantive area
- appropriate, credible resources - subject matter experts, limited focus, understand protocols
- ownership and accountability for resolution at appropriate level
- follow-up to assure resolutions in place Creating/Updating Annual Compliance Audit and Monitoring Plan - VERIFIED ANSWER✔✔-1. conduct a risk assessment
- prioritize risks identified
- identify resources that will be needed for implementing the plan
- obtain buy-in
- document process of developing your plan
- evaluation (did meet goals, use resources appropriately, effectiveness, value added, client satisfaction)
- proceed with finalizing the plan Conducting a Compliance Audit - OIG Probe Audit Approach - VERIFIED ANSWER✔✔-1. sample of 20- units that is not statistically significant (may be less in some cases) (*)
- if error greater than 5%, conduct statistically significant sample
- think through error rate (what is denominator?)
- used first in for-cause audits to determine if a problem exists (*)
Conducting a Compliance Audit - Statistical Approach (*) - VERIFIED ANSWER✔✔-1. involves randomly selecting claims in a sample where every member has equal probability of being selected
- sample must be selected at random (no bias)
- results can be extrapolated to make assumptions about the population universe
- precision and confidence indicates an acceptable level of sampling error Corporate Integrity Agreements - Discovery Samples (auditing) - VERIFIED ANSWER✔✔-1. discover sample - usually 50 claims (*)
- error rate less than 5% - no additional sampling required
- 5% or greater error rate - full sample required (size determined by discovery sample)
- full sample must estimate overpayment in population with 90% confidence level and maximum relative precision of 25% to the point of estimate () Consider Attorney Advice/Privilege - Retrospective Approach to Obtaining Audit Sample () - VERIFIED ANSWER✔✔-1. need a milestone to go back (ex: change in system, new people, new system, new rule, etc.)
- worst way to change behavior
- easy to access information
- statistical model easier to develop (know sample unit) Consider Attorney Advice/Privilege - Concurrent Approach to Obtaining Audit Sample - VERIFIED ANSWER✔✔-1. any time up to the final , usually "real time"
- best way to change behavior
- access to information is difficult due to "current" nature of documents
- statistical model more difficult to determine Monitor and Audit Process (*) - VERIFIED ANSWER✔✔-1. define review scope and assumptions (interviews, review policies/procedures/education/training, document)
- develop review criteria (test review criteria, inter-rater reliability testing [give auditors same charts and see if get same results], enter criteria in database)
- conduct review (review documents, enter findings)
- understanding by all members of the organization as to disciplinary measures, fairness, and consistency Response - VERIFIED ANSWER✔✔-1. triage investigations - defined in policy at high level
- decision tree for how matters are handled
- matters assigned to other departments should be tracked to ensure resolution
- investigations conducted by trained investigators Prior to Beginning Investigation - VERIFIED ANSWER✔✔-Determine:
- who will make the decision on findings
- what is investigative process
- format of reports
- document retention/destruction defined
- consider attorney-client privilege Preventative Measures - VERIFIED ANSWER✔✔-1. resolution of issues is the goal (find root cause)
- analysis of issues and identification of patterns/trends can prevent reoccurrence
- monitor remediation efforts to ensure timeliness and adequacy addressing primary issue Common Remediation Areas - VERIFIED ANSWER✔✔-1. Education (due to lack of knowledge)
- Policies and Procedures (due to unclear expectations and/or not in a written policy) Evaluating Effectiveness - VERIFIED ANSWER✔✔-1. Program metrics (hotline calls, incidents, etc.)
- surveys
- focus groups
- testing
- self-assessments
- exit interviews
- periodic risk assessment, internal audit reports, etc.
Enforcement Environment - VERIFIED ANSWER✔✔-Heightened scrutiny Enforcement Activity - VERIFIED ANSWER✔✔-Recoveries are paying for the investigations Enforcement Weapons - VERIFIED ANSWER✔✔-Forensic data mining, tracking/trending, etc. Compliance should serve as catalyst to... - VERIFIED ANSWER✔✔-1. build capacity throughout the institution (make people aware)
- identify vulnerabilities (weaknesses)
- lead the design of systems to respond to needs (ongoing; make things happen) Compliance cannot implement control processes because... - VERIFIED ANSWER✔✔-it takes away independence. A compliance program is never _____, it should always be ____. - VERIFIED ANSWER✔✔-finished; a work in progress. Establish a _____, be assured that ______, then focus on _____. - VERIFIED ANSWER✔✔-framework; elements are working; effectiveness (outcomes based) Policies and Procedures - VERIFIED ANSWER✔✔-1. makes clear to employees how they should act
- may improve efficiency and workflow
- brings consistency and clarity can have a policy without procedure but not procedure without policy Policy (definition) - VERIFIED ANSWER✔✔-1. statement of an approach to an issue
- guidance on governing principle
- rules that govern the organization
