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HCCA - CHC Study Questions/ Content covers
each compliance program element, HIPAA
terms, compliance related laws & regulations,
study materials, and general definitions and
acronyms
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 - 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 - Answer: b. increasing management involvement Which of the following requires providers to be permanently excluded from all federal health care programs if found guilty of a healthcare related fraud a third time: a. Deficit Reduction Act of 2005 b. False Claims Act c. Balance Budget Act of 1997 d. Social Security Act section 1128 - Answer: c. Balance Budget Act of 1997 Also known as a BBA "three strikes rule" Which statement is TRUE regarding compliance programs? a. Compliance programs are considered more dangerous if they are developed but not implemented. b. Compliance programs can detect but not prevent criminal conduct c. Compliance programs are only required by law for healthcare entities that have more than $500,000 in annual revenue. d. Compliance programs are not mandated by law. - Answer: a. Compliance programs are considered more dangerous if they are developed but not implemented. Formal statement outlining a plan for a specified subject area. It usually cites state and/or federal required actions or standards. a. CAP b. Procedure document c. Policy document d. Legal standards - Answer: c. Policy document CAP - outlines corrective action plan Procedure - describes process/steps under a certain criteria
Code of Conduct Purpose - 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: - 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? - 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 - 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? - Answer: Code of Conduct In the course of an audit, you find that disciplinary actions against certain physicians and high level executives for non-compliance in the organization have been unfair and inconsistent with current policies & procedures. What is your first course of action .a. Work with legal counsel to enforce proper disciplinary actions b. Get HR involved and recommend the use of progressive discipline policies c. Immediately terminate these individuals d. Get local and federal labor department involved for unfair discipline. - Answer: b. Get HR involved and recommend the use of progressive discipline policies OIG recommends setting forth the degrees of disciplinary actions. Progressive discipline provides a structure and a set of discipline standards for managers/supervisors to follow to ensure discipline is fair, equitable and consistent. Documentation - Answer: • A&M should be documented
- Findings should be shared with dept managers
- If activity is part of risk priority then compliance committee, senior leadership and board when necessary
- OIG calls for written evaluation to be presented to CEO, governing body, committee annually
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. - 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 - 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 - 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 - 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.
- The right to receive an accounting of disclosures of PHI as provided by § 164.528.
- The right to receive a paper copy of the NPP upon request.
- A brief description of how the individual may exercise the foregoing rights, e.g., by submitting a written request to the provider's privacy officer.
c. Neither - 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 - 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 - Answer: d. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider's knowledge? Yes No - 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 - 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 - 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.
DOL oversees employment discrimination DOJ enforces federal criminal law and implements criminal law policies OIG combats FWA in Medicare, Medicaid and HHS Programs Note: practice question from AAPC CPCO Ch 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 - 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 - 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 - 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. - 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 - 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?
For purposes of reporting the overpayment to the OIG, underpayments may be netted (or offset) from overpayments. However, in terms of repaying the overpayment to the appropriate payor, the provider should consult with that payor as to whether it will allow underpayments to be netted from overpayments for collection purposes. https://www.americanbar.org/content/dam/aba/administrative/healthlaw/ 14_emerging_trends_in_false_claims_act_damages_settlements_07.authcheckdam.pdf The following questions would be pertinent to every organization to help the __________________ professional in reviewing policies and procedures that need to be addressed: Does the organization employ non-physician practitioners? Does the organization perform services in a rural clinic settings? Does the organization provide medical services that fall under the Physicians at Teaching Hospital (PATH) rules? Does the organization participate in clinical trials (research)? a. Human Resources Director b. Chief of Hospital Operations c. Chief of Compliance d. Medical Staff Services - 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 - 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 - 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 - Answer: "Care Financing" See HFCA Ruling No. 86-1 (Feb. 20, 1986). One of the most important foundations of your compliance program is:
- Minimizes financial losses
- Encourages employees to report compliance problems/issues What are the two primary objectives of a Board of Directors (BOD)? - Answer: 1. Duty of Care decision making
- Oversight function (BOD can delegate to CEO) What are the two primary focus areas of a Board of Directors (BOD) in compliance? - Answer: 1
- structural (need to understand compliance program SOW) 2 - operational (need to understand compliance program needs to operate) What does Duty of Care mean for BOD? - Answer: 1. act in good faith
- level of care a prudent person would (avoid negligence)
- protect welfare of organization, act in a manner that's best for all What are the three roles of a board member? - Answer: 1.Compliance oversight. 2.Structuring your compliance program 3.Evaluating effectiveness of the compliance standards and processes. When creating and implementing a compliance plan, the compliance officer should have: A. no approval B. board approval and resolution C. patient approval D. legal approval - Answer: B. board approval and resolution What can an effective compliance program do? - 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 - 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 - 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 - 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.
