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HCCA CHC New Study Set Questions And
Verified Detailed Answers
Deficit Reduction Act of 2005-ANSWER The organizations receiving more than $5 million in Medicaid funds have to provide education on the False Claims Act.
Corporate Integrity Agreement (CIA) - ANSWER A compliance program required by the government, which is characterized by substantial government oversight and independent expert involvement in the organization's compliance activities and usually must be accepted as part of the settlement of fraud and abuse investigation. Negotiated primarily between the OIG and the health care entity.
Seven Elements of a Compliance Program - ANSWER 1. Standards of Conduct
- Oversight & Resources
- Education & Training
- Auditing and Monitoring
- Consistent and appropriate discipline
- Reporting Processes
- Response and Prevention of Problems
LEIE List of Excluded Individuals - ANSWER A list of individuals and organizations that are excluded from participating/billing the federal healthcare program ie. Medicare. This list is updated monthly and it is the responsibility of the organization to check their list of physicians, employees, etc. against this to prevent a violation of the False Claims Act.
Medicare Cost Report - ANSWER A report that contains provider information such as facility characteristics, utilization data, cost and charges by the cost center. If administrator's or business associate pay appears on this that is excluded from the LEIE, it may be liable as a FCA.
5 to 50 Years - ANSWER Mandatory Exclusion (felony) length
Up to 5 Years - ANSWER Permissive exclusion (misdemeanor) length
State Medicaid Exclusion List - ANSWER State Version of LEIE, also screened monthly
False Claims Act - ANSWER Prohibits anyone from knowingly presenting or causing to be presented a false or fraudulent claim for payment to the government.
Anti-Kickback Law - ANSWER Prohibits soliciting, receiving, offering, or paying of any remuneration directly or indirectly in cash or in kind as consideration in exchange that are payable by a federal Healthcare program.
Anti-Kickback Safe Harbors ANSWER 1. Referrals made as part of an employment or professional services agreement
- Payments made for the lease equipment or of office space
- Certain payments made for the purposes of health practitioner recruitment.
Stark Law ANSWER Part of OBRA, bans physicians from referring lab specimens or other DHS to any entity with which the physician has a financial relationship.
Balance Budget Act - ANSWER Legislation containing major reform of Medicare and Medicaid programs especially in the areas of home health and patient transfers. It mandates permanent exclusion from participation in federally funded healthcare programs of those convicted of three healthcare related crimes.
HITECH ANSWER Enacted as part of ARRA, HITECH is a law that is aimed at incentivizing healthcare providers to adopt health information technology in a manner that establishes electronic health records in a standardized way that protects patient's private health information.
HIPAA - ANSWER Comprehensive legislation that provides for the continuation of health coverage for unemployed workers who have lost their jobs or are between jobs. It also
3 Steps of Auditing and Monitoring of Billing-ANSWER 1. Determine what laws and policies are applicable to your practice. Found on CMS website or private payor contract.
- Conduct a Baseline Audit or "snapshot" audit of coding and billing within 3 months after initial education and training. To be repeated yearly and yields practice risk areas.
- Establish plan for managing those risks through the practice standards and procedures.
OIG 3 Steps for Educational Objectives - ANSWER 1. Identify who should be trained.
- Identify the type of training that will serve the needs of the practice.
- When and how often education is needed and how many hours each should receive.
Health Reform Act - ANSWER Requires providers to refund an overpayment to Medicare within 60 days of "identifying" it and provides that an overpayment retained beyond that deadline is an "obligation" under the FCA.
- At minimum take them out of service for a time period. Discuss duration with Legal
- Any paperwork related to the exclusion should be reviewed and the individual should only be returned to duty when there is documentation or reinstatement
- An analysis is done to first determine whether the person or entity was properly excluded and the correct timeframe. Then the items or services they ordered or prescribed would be examined. If not services, then person's salary or contract would be analyzed to determine if they affect payment under a Medicare or Medicaid cost report. - ANSWER Steps you do when you find out someone is excluded (LEIE) from billing the federal program
Fraud Enforcement Recovery Act- ANSWER Establishes a "reverse false claims" provision assessing treble damages against any person who "knowingly and improperly avoids or decreases an obligation to pay or transmit money to the government.
concurrent audit- ANSWER Continuous examination or records, policies and procedures. Best practice for compliance audits.
whistleblower- ANSWER Provides original information to the government regarding fraud in organizations.
"In-office" Ancillary Services Stark Exception - ANSWER Services furnished by the referring physician, another physician in the same group practice, or personally by individuals directly supervised by the physician or another physician in the group practice.
Caremark International Derivative Litigation - ANSWER Litigation that makes board responsible for implementation of a system to gather information on the company's efforts to prevent and detect fraud and abuse.
Obtain management, Board, and operations buy-in and commitment. - ANSWER First step in compliance program development.
Culpability Score - ANSWER A numerical rating of organization's guilt/responsibility. Applies to the amount of fines applied.
Aggravating Factors - ANSWER Per FSG, how would the following have an effect on a culpability score:
- Organization's high Level involvement
- Obstruction of justice
- The offense was in violation of a judicial order
- Prior misconduct
Mitigation Factors - ANSWER Per FSG, how would the following affect a culpability score:
- Cooperated with investigation
- Accepted Responsibility
- Self- Reported
hybrid covered entity - ANSWER An organization whose activities include both covered and noncovered functions under HIPAA
Upcoding - ANSWER Using a billing code that provides a higher reimbursement rate than the billing code that actually reflects the service furnished.
Unbundling - ANSWER The illegal practice of submitting claims individually for tests or procedures which should be billed together in order to maximize reimbursement.
DRG creep - ANSWER Billing using a DRG code that has a higher payment rate than the proper DRG code which most accurately reflects the service provided.
72 Hour Window Rule - ANSWER Pre-admission testing & procedures: "Pre-admission diagnostic tests performed as an outpatient within 72 hours of admission are to be billed as part of the admission DRG.
Attestation - ANSWER At the end of training, all employees/consultants must sign and date a statement acknowledging awareness of standards of conduct.
Retrospective audit - ANSWER An audit that essentially is a "baseline audit", or snapshot of what was. Thorough review of records, policies, and procedures completed in advance of implementing a compliance program. The baseline audit provides benchmarks for future measurements.
Fiscal Intermediary - ANSWER An individual and/or agency that processes claims, performs services, and publishes payments on behalf of private, federal or stat benefit programs.
Voluntary Disclosure - ANSWER The organization immediately reports on itself (within 60 days). Qui tam much less likely and substantially reduces the damages imposed.
ACE-Affiliated Covered Entity Legally separate covered entities that are affiliated may designate themselves as a single covered entity for purposes of the HIPAA privacy rule.
Common ownership exists if an entity possesses 5% or greater ownership in another entity.
Administrative Simplification Section of Title II The section of HIPAA that required standardized transaction standards for content and transmission of data.
OCR and the individual - ANSWER Whom would you report a breach of PHI to?
written authorization - ANSWER What does an organization have the right to request when an Individual requests access to their PHI?
5 years - ANSWER According to the Medicare's conditions of participation, for how many years should medical records be retained?
Medicare Conditions of Participation- ANSWER Health and safety standards that must be met in order to bill Medicare for services. (Quality of care issues)
HIPAA 1996 - ANSWER Under what Act is it a criminal defense to submit claims based on incorrect codes or unnecessary services?
