Download Healthcare Compliance Study Questions and Answers and more Exams Nursing in PDF only on Docsity!
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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). - correct answer ✅True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) - correct 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 - correct answer ✅c.. third level of appeal Frist level - redetermination by Medicare contractor
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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. - correct 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 - correct answer ✅c. non-retaliation for whistleblowers
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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. - correct 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 - correct answer ✅c. Policy document CAP - outlines corrective action plan Procedure - describes process/steps under a certain criteria Legal standards - mandatory action or rule Life cycle of records management - correct answer ✅Creation Use
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Maintenance Retention Disposition Standards of Conduct (written P&Ps) - correct 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 - correct 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 - correct 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
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When should Code of Conduct be distributed to new employees? - correct 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 - correct 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? - correct 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
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d. Get local and federal labor department involved for unfair discipline. - correct 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 - correct 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 Non-retaliation in compliance - what is important to state in this policy: - correct answer ✅For any reporting method to be effective, employees must accept that there will be no retaliation or retribution for coming forward. The concept of non-retaliation is fundamental to the compliance program, and a clearly stated policy regarding non-retribution is the first step.
- anonymous reporting and,
- no retaliation or retribution for bringing forth problems/concerns Place to start with Enforcement is: - correct answer ✅Standards of conduct and P&Ps
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requirements. - correct 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 - correct 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 - correct 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
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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 - correct 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.
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FRAUD is intentional (knowingly/willfully); WASTE is overuse/misuse of resources carelessly; ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses 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 - correct 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 - correct answer ✅a. established by the DRA of 2005 (section 6034) https://www.ssa.gov/OP_Home/comp2/F109-171.html Notes:
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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 - correct answer ✅d. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider's knowledge? Yes No - correct 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 - correct answer ✅d. all of the above
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The code of conduct should address the organization's: a. Culture b. Beliefs c. Ethical position d. All of the above - correct answer ✅d. All of the above When developing an effective code of conduct, an organization should consider: a. Soliciting another organization's code and tweaking it to fit b. Methods for reporting issues c. Zero tolerance for fraud and abuse d. B and C - correct answer ✅d. B and C Sue works for ABC Family Physicians. The providers at this office ask her to research the department that helps protect patients from unfair treatment or discrimination. What department or agency would that be? a. Equality in Employment Agency b. Office for Civil Rights c. Department of Justice d. Office of Inspector General - correct answer ✅b. Office for Civil Rights (OCR) DOL oversees employment discrimination DOJ enforces federal criminal law and implements criminal law policies OIG combats FWA in Medicare, Medicaid and HHS Programs
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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 - correct 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 - correct answer ✅a. HHS Office of Inspector General Note: practice question from AAPC CPCO Ch
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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 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 - correct 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: A hospital with an imposed-CIA performs a discovery sample as part of the Claim Review and finds it has a financial error rate above 5%. OIG requires that the hospital then conducts a full sample. - correct answer ✅TRUE
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Probe and Discovery Samples are used to get an initial glimpse and seriousness of a problem to determine if the size of a Full Sample is needed. For example, in Corporate Integrity Agreements (CIA) the OIG requires a Full Sample to be used, if the overpayment error rate, or financial error rate, in a Discovery Sample is at or above 5%. https://oig.hhs.gov/faqs/corporate-integrity-agreements-faq.asp https://www.americanbar.org/content/dam/aba/administrative/healthlaw/ 14_emerging_trends_in_false_claims_act_damages_settlements_07.authcheckda m.pdf True or False: If an IRO identifies any underpayments during a CIA-Claim Review for a hospital, these may be netted (or offset) from overpayments. The hospital may also consult with the appropriate payor to ensure if the underpayment amounts can be used against outstanding overpayments. - correct answer ✅TRUE 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.authcheckda m.pdf
