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HCCA - CHC Study Questions (MASTER
FLASHCARDS) with complete solutions
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). - VERIFIED ANSWER✔✔-True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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. - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-d. will not be successful without the proper oversight 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 - VERIFIED ANSWER✔✔-b. increasing management involvement
Maintenance Retention Disposition Standards of Conduct (written P&Ps) - VERIFIED ANSWER✔✔-Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations Code of Conduct: Content Checklist - VERIFIED ANSWER✔✔-• 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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-• 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: - VERIFIED ANSWER✔✔-• 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? - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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? - VERIFIED ANSWER✔✔-Code of Conduct
- list parties responsible for appropriate action
- outline of disciplinary actions or procedures
- promise that discipline will be fair and consistent New Employee Policy - three checks OIG recommends to do/perform: - VERIFIED ANSWER✔✔-OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? - VERIFIED ANSWER✔✔-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. - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-A) Code of Conduct
The U.S. Federal Sentencing Commission was organized in _____, published its initial set of guidelines in _____, and included chapter eight of the Federal Sentencing Guidelines for Organizations (FSGO) in _____. a. 1980, 1987, 1999 b. 1985, 1987, 1991 c. 1980, 1985, 1987 d. 1985, 1990, 2001 - VERIFIED ANSWER✔✔-b. 1985, 1987, 1991 "The privacy officer for a hospital has updated the Notice of Privacy Practices 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 third 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 have copies of the new NPP mailed to all patients seen within the last year at the hospital B. Make arrangements to have the new notice distributed to new patients that come to the hospital C. Post a copy of the new notice 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 the OCR that the hospital was in violation of the NPP requirements and has since - VERIFIED ANSWER✔✔-B. Make arrangements to have the new notice 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.
- 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.
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 - VERIFIED ANSWER✔✔-a. Fraud Upcoding - is a type of fraud (knowing/intentionally) coding more expensive codes for higher reimbursement What is true about Medicaid Integrity Programs: a. established by the DRA of 2005 b. federally administered and state monitored c. audited by MACs d. created to combat Medicare provider FWA - VERIFIED ANSWER✔✔-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 (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 - VERIFIED ANSWER✔✔-d. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider's knowledge? Yes
No - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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. - VERIFIED ANSWER✔✔-c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.
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 - VERIFIED ANSWER✔✔-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 Ch 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 - VERIFIED ANSWER✔✔-a. HHS Office of Inspector General Note: practice question from AAPC CPCO Ch 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 - VERIFIED ANSWER✔✔-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 Ch 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. - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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:
b. Chief of Hospital Operations c. Chief of Compliance d. Medical Staff Services - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-"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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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. - VERIFIED ANSWER✔✔-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? - VERIFIED ANSWER✔✔-(OQC: Operations, Quality and Costs)
C. patient approval D. legal approval - VERIFIED ANSWER✔✔-B. board approval and resolution What can an effective compliance program do? - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 - VERIFIED ANSWER✔✔-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 Ch 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 - VERIFIED ANSWER✔✔-c. Enroll in the CLIA program Note: practice question from AAPC CPCO Ch
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. - VERIFIED ANSWER✔✔-a. No, a CLIA number is not required if the facility only collects specimens and performs no testing. Note: practice question from AAPC CPCO Ch 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 - VERIFIED ANSWER✔✔-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 Ch Seven basic elements for a fundamental compliance program as per HCCA CHC exam? - VERIFIED ANSWER✔✔-1. Standards and Written Policies & Procedures
- Compliance Program Admin (CO and Board oversight)
- Effective Education &Training
- Screening and Evaluation (Employees, Physicians, Vendors)
- Communication, Edu & Training
- Auditing & Monitoring, Internal Reporting System
