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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/ 198 Q&A.
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). - Answer: True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) - 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 - 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. - 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. 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 Legal standards - mandatory action or rule Life cycle of records management - Answer: Creation Use Maintenance Retention Disposition Standards of Conduct (written P&Ps) - 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 - 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 - 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 - 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
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 Non-retaliation in compliance - what is important to state in this policy: - 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: - Answer: Standards of conduct and P&Ps For Enforcement and Disciplinary Actions, Policies should include: - Answer: 1. non-compliant consequences
- employees duty to report non-compliance
- 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: - Answer: OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? - 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. - 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
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. What is the best definition of Medicare/Medicaid fraud? a. Attempting a scheme against the Medicare/Medicaid program b. Knowingly executing a scheme against the Medicare/Medicaid program c. Willfully executing a scheme against the Medicare/Medicaid program d. All of the above - Answer: d. All of the above Remember: Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme. FRAUD is intentional; 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 What is the best definition of Medicare/Medicaid abuse? a. Knowingly defrauding the Medicare/Medicaid program b. Intentionally violating Medicare/Medicaid guidelines
c. Unknowingly violating Medicare/Medicaid guidelines d. None of the above - Answer: c. Unknowingly violating Medicare/Medicaid guidelines 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 - 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)
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. d. Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. - Answer: c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. The entity's level of commitment to compliance is directly related to the resources (human and financial) a. True b. False - Answer: b. False The code of conduct should address the organization's: a. Culture b. Beliefs c. Ethical position d. All of the above - 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 - 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 - 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 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 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? 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 - 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. - Answer: TRUE 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.authcheckdam.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. - 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.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
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: a. The Compliance Policy Manual b. The Organization Code of Conduct c. The non-retaliation policy d. Adequate staffing and information systems - 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 - 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. - 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? - Answer: (OQC: Operations, Quality and Costs) Enhance your organization's operations, improve quality of patient care and reduce overall costs What are the benefits to a Compliance Program? - Answer: 1. Commitment to Code of Conduct.
- Prevent, detect, and correct unethical behaviors.
- 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:
