CPCO

Dr. X is on call at ABC Hospital. There is a major accident on the local freeway and the emergency department calls Dr. X to respond. Dr. X has fallen asleep and does not respond to the page. Under EMTALA, what is the maximum penalty (prior to inflation) that Dr. X can be charged per violation? a. $50,000 b. $100,000 c. $75,000 d. $10,000

a. $50,000

The OIG requires that documents relating to the CIA be kept for how long after the CIA term? a. 1 year b. 2 years c. 6 years d. 7 years

a. 1 year

What year did OSHA publish the Bloodborne Pathogens Standard? a. 1991 b. 1996 c. 2001 d. 2002

a. 1991

What year did HITECH Act get implemented? a. 2009 b. 2008 c. 2007 d. 2005

a. 2009

In what year was the Patient Protection and Affordable Care Act (PPACA) enacted? a. 2010 b. 1996 c. 2001 d. 2008

a. 2010 Rationale: The Patient Protection and Affordable Care Act was signed by President Obama on March 23, 2010.

Changes in ownership must be reported within how many days to the Medicare program? a. 30 b. 60 c. 45 d. 90

a. 30

After enacting CLIA, by what percentage did the total number of quality deficiencies decrease from the first laboratory survey to the second? a. 40% b. 46% c. 52% d. 80%

a. 40%

Which Code of Federal Regulation section is important to compliance officers, and why? a. 42; It covers the Medicare and Medicaid programs. b. 42; It covers practice management rules. c. 40; It covers military insurance issues. d. 40; It covers HIPAA privacy rules.

a. 42; It covers the Medicare and Medicaid programs.

When it is the intention of an organization to provide a safe environment to patients, what should the organization design? a. Patient bill of rights b. HIPAA statements c. Compliance policy d. Patient portal

a. Patient bill of rights

What is it called when a hospital sends a patient home or transfers the patient without providing care? a. Patient dumping b. A referral c. An inappropriate discharge d. Home discharge

a. Patient dumping

Par is an acronym meaning what ? a. Physicians agree to take assignment on all Medicare claims b. Physicians will not take assignment on all Medicare claims c. Physicians agree to take 100 percent on all Medicare claims d. Physicians agree to reassign payment on all Medicare claims

a. Physicians agree to take assignment on all Medicare claims Rationale: PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount (generally, Medicare pays 80 percent and the patient pays 20 percent in copayments) as payment in full for all covered services for the duration of the calendar year.

MACs can initiate an investigation if there is a complaint or if something about the billing profile is triggering flags. If quality concerns are an issue, what type of organization may be involved? a. QIO b. OSHA c. MEDIC d. CLIA

a. QIO MACs can initiate an investigation if there is a complaint, or if something about the billing profile is triggering flags. If quality concerns are an issue, the CMS Regional Office, the state surveyors, or the state Quality Improvement Organization (QIO) may be involved.

What was established by Congress for all laboratory testing under the Clinical Laboratory Improvement Amendments (CLIA) in 1988? a. Quality standards b. New equipment regulations c. New staffing quota requirements d. Training qualifications

a. Quality standards

Circumnavigation schemes can occur when a physician or other entity enters an arrangement that the entity or physician knows that they will receive what in return? a. Referrals b. Gifts c. P d. Patient transfers

a. Referrals Rationale: So-called "circumnavigation schemes" may result in monetary penalties of up to $100,000 for each arrangement or scheme and exclusion from government programs. These occur when a physician or other entity enters an arrangement or scheme (such as a cross-referral arrangement) that the entity or person knew, or should have known, had the principal purpose of assuring referrals (which, if they had been made directly, would have been prohibited).

Which one of the following is NOT an administrative sanction for fraud committed against the Medicare and Medicaid programs? a. Revocation of Aetna enrollment b. Exclusion c. Deactivation d. Revocation of Medicare enrollment

a. Revocation of Aetna enrollment

Which of the following best describes UPICs? a. UPICs are private companies contracted by CMS. b. UPICs are paid by grant monies. c. UPICs only cover certain states where fraud is prevalent. d. UPICs are federally funded.

a. UPICs are private companies contracted by CMS.

Which one of the following is a requirement of MCFUs? a. Units must employ attorneys. b. Units must use up all of their grant money by fourth quarter. c. Units must employ nurses for clinical questions. d. Units must employ a certain amount of minorities.

a. Units must employ attorneys.

How often should healthcare workers (HCW) receive TB testing in a medium risk facility? a. Upon hire and every year b. Upon hire and twice a year thereafter c. Upon hire and every 5 years d. Upon hire and then only if sick

a. Upon hire and every year

The medical records department at Apple Rural Health Center asks Kim, the compliance officer, how far they need to go back to give a patient an accounting of the PHI disclosures on their account? What should be Kim's response? a. 1 year b. 3 years c. 4 years d. 6 years

d. 6 years

What is the maximum number of days, after determining that there is credible evidence of fraudulent conduct, a billing company should take to notify federal and state authorities regarding the violation? a. 10 b. 15 c. 30 d. 60

d. 60 Rationale: If the billing company discovers credible evidence of the provider's continued misconduct or flagrant fraudulent or abusive conduct, the billing company should: (1) Refrain from submitting any false or inappropriate claims; (2) terminate the contract; and/or (3) report the misconduct to the appropriate federal and state authorities within 60 days.

Skilled Nursing Facilities (SNFs) are Medicare certified facilities that provide extended skilled nursing or rehabilitative care. This care is reimbursed under which Medicare part(s)? a. A b. B c. C d. Part A and Part B

d. A and B Rationale: SNFs are typically reimbursed under Part A for the costs of most items and services, including room, board, and ancillary items and services. However, SNFs may also receive payment under Medicare Part B.

Under the Medicare regulations, when a prospective payment system (PPS) hospital transfers a patient to another PPS hospital, only the hospital to which the patient was transferred may charge the full DRG. What should the transferring hospital charge Medicare? a. An ambulance fee b. A fee for the ER bed used c. The provider charges only d. A per diem amount

d. A per diem amount

A basic concept in the anti-kickback safe harbors and Stark exceptions is that financial transactions between potential referring parties be conducted under what condition? a. In an outpatient facility b. In a hospital setting c. Fair market value d. A referral on file

d. A referral on file

What key item(s) can protect a medical practice from harassment liability? a. Keys to the office b. Management plans c. Physical safeguards d. A zero-tolerance policy for harassment

d. A zero-tolerance policy for harassment

What term would be used for actions that, either directly or indirectly, result in unnecessary costs to the Medicare program? a. Fraud b. Mistake c. Waste d. Abuse

d. Abuse Rationale: "Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program."

Sofie works at Apple Rural Health Center. Her husband just returned from active duty and was injured; she needs to take time off to take care of her husband and get the household stabilized. How much time can Sofie take off? a. 10 weeks b. 12 weeks c. 6 weeks d. 26 weeks

d. 26 weeks

Remuneration for referrals affects the quality of patient care by encouraging physicians to order services or supplies based on profit rather than the patients' best medical interests, and is what? a. Legal if done properly with a contract b. Encouraged under the ACA c. Discouraged d. Illegal

d. Illegal

Which of the following is not classified as a Federal Health Care Provider Conscience Protection Law? a. The Church Amendments b. Section 245 of the Public Health Service Act c. Weldon Amendment d. The Civil Rights Act of 1964

d. The Civil Rights Act of 1964

Whose responsibility is it to focus on the key risk areas through education and documented audit improvement? a. The front desk staff b. The providers c. The nursing supervisor d. The compliance officer

d. The compliance officer

The DOJ's current strategic plan (2018-2022) includes the following overarching goals:

- Enhance national security and counter the threat of terrorism; - Secure the borders and enhance immigration enforcement and adjudication; - Reduce violent crime and promote public safety; and - Promote rule of law, integrity, and good government.

Which area is NOT covered under EMTALA? A. A physical therapy department of the hospital located in a new office complex located two miles from the hospital. B. A provider-based department that is licensed as an emergency department. C. A hospital owned/operated physician practice that provides advertised emergency care in an urgent care clinic located 10 miles from the hospital. D. The hospital parking lot.

A. A physical therapy department of the hospital located in a new office complex located two miles from the hospital.

Under the HIPAA privacy rule, which of the following situations would require an authorization from the patient to release records? A. A request from a life insurance company for the patient's medical records. B. A request from the patient's primary care physician to the surgeon regarding the patient's recent surgical procedure. C. A patient requests a copy of her lab work. D. A patient's insurance company requests a copy of the patient's medical record to complete processing of a claim.

A. A request from a life insurance company for the patient's medical records.

Developing effective compliance policies and procedures is an important part of any compliance program. To help your practice mitigate compliance risk, policies and procedures should: A. Only be one page long to promote understanding by all staff. B. Be sure any timeframes or requirements listed can be accomplished given the practice's resources. C. Be written by consultants because they are more familiar with the variety of healthcare regulations that apply to the practice. D. Both B and C

B. Be sure any timeframes or requirements listed can be accomplished given the practice's resources.

Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) - Pub. L. 108-173, December 8, 2003 - authorized an exception to the physician self-referral prohibition for certain arrangements in which the physician can receive necessary non-monetary remuneration. What is this exception related to? A. Outpatient services B. E-Prescribing C. Physician investments in specialty hospitals D. None of the above; there are no exceptions in the Stark law.

B. E-Prescribing

When conducting compliance training within a physician practice, what is one of the goals that the practice should strive for in this training? A. Only new employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations. B. Managers of employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations. C. All employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations. D. All employees will receive training on the definition of compliance.

C. All employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations.

Billing companies should have written policies and procedures that reflect and reinforce Federal and State statutes. These policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the health care provider. Which one of the following policies and procedures should a billing office have in place to meet these needs? A. Conclude that claims may be submitted when note has been started but not yet finalized by the physician as long as a signed affidavit is in place in the office granting the staff power to provide coding based on preliminary reports. B. Provide incentives to billing and coding staff in the form of compensation for productivity to ensure full revenue recovery of all claims in a timely fashion. C. Establish and maintain a process for pre- and post-submission review of claims to ensure claims submitted for reimbursement accurately represent services provided, are supported by sufficient documentation and are in conformity with any applicable coverage criteria for reimbursement D. Emphasize that claims may be submitted on behalf of the physician as long as they include the reason for the encounter, the time involved, and a documented treatment plan.

C. Establish and maintain a process for pre- and post-submission review of claims to ensure claims submitted for reimbursement accurately represent services provided, are supported by sufficient documentation and are in conformity with any applicable coverage criteria for reimbursement

Which one of the following events would require the practice to update their CLIA certificate information within 30 days? A. Dr. Hansen is part of a small group practice with Dr. Miller and three Physician Assistants. Dr. Miller is retiring and leaving the practice. Dr. Hansen is listed on the CLIA certificate as the owner/medical director. B. Family Foundation is a medical group focusing on family practice/pediatric care. They received a notice in the mail that it's time to renew their CLIA certificate. C. Good Care medical clinic is excited to be moving to a new location. It is a brand new building right across the street from their current location. They chose this location because it would be the most convenient for their patients. D. When a new test is performed that is not covered under the practice's current CLIA certificate.

C. Good Care medical clinic is excited to be moving to a new location. It is a brand new building right across the street from their current location. They chose this location because it would be the most convenient for their patients.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, what is the name of the national program designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse? A. Health Care Fraud Prevention and Enforcement Action Team (HEAT) B. Health Care Recovery and Affordable Care Act (HCRAC) C. Health Care Fraud and Abuse Control Program (HCFAC) D. Health Care Civil Penalties Law

C. Health Care Fraud and Abuse Control Program (HCFAC)

A safeguard the security officer puts in place is that all employees were given name tags to wear while on duty. Policies were put in place to restrict access to employee areas. Policies were also written to establish the proper use of computer workstations for business and antivirus software was added.What type of safeguard does this action describe? A. Technical safeguards B. Lifesaving safeguards C. Physical safeguards D. Administrative safeguards

C. Physical safeguards

Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other suppliers request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. As a result of a physician accepting assignment, the physician must follow certain requirements. Which statement does NOT accurately reflect the requirements of physicians accepting assignment? A. The physician/supplier who accepts assignment on a claim-by-claim basis or who is a participating physician/supplier is precluded from charging the enrollee more than the deductible and coinsurance based upon the approved payment amount determination. B. Physicians or suppliers who agree to accept assignment from Medicare cannot attempt to collect more than the appropriate Medicare deductible and coinsurance amounts from the beneficiary, his/her other insurance, or anyone else. C. Physicians or suppliers who have chosen to accept assignment may as a result collect from the enrollee or anyone else any amount which, when added to the benefit, may exceed the Medicare allowed amount. D. A physician/supplier may not attempt to circumvent the Medicare allowed amount limitation by "fragmenting" his/her bills.

C. Physicians or suppliers who have chosen to accept assignment may as a result collect from the enrollee or anyone else any amount which, when added to the benefit, may exceed the Medicare allowed amount.

The civil False Claims Act provides the Court with the authority to assess: A. One "times the amount of the damages which the Government sustains..." B. Up to two "times the amount of the damages which the Government sustains..." C. Up to three "times the amount of the damages which the Government sustains..." D. Up to four "times the amount of the damages which the Government sustains..."

C. Up to three "times the amount of the damages which the Government sustains..."

A compliance program's plan for communication should include a provision for non-retaliation for reporting fraudulent conduct. Which method below helps ensure that an employee would be free from retribution? A. A clearly defined chain of command for reporting potentially fraudulent conduct B. Guaranteed anonymity C. Well-publicized disciplinary actions for retaliation D. A policy that encourages reporting directly to the OIG

C. Well-publicized disciplinary actions for retaliation

1999

Compliance Program Guidance for DME industry, Hospices and Medicare+Choice Organization.

2000

Compliance Program Guidance for Nsg Facilities & Individual & Small Grp Physician Practices.

The HIPAA security rules require covered entities to put safeguards in place to protect personal health information. A medical facility hired a Security Officer who had done a risk analysis to identity potential security risks of the computer system. He has implemented policies and procedures on computer access and password management. What type of safeguard does this action describe? A. Technical safeguards B. Lifesaving safeguards C. Physical safeguards D. Administrative safeguards

D. Administrative safeguards

There can be a variety of risks associated with joint ventures between hospitals and physicians. What law(s) could be violated for improper joint ventures? A. False Claims Act B. Stark Laws C. Anti-kickback Statute D. All of the above

D. All of the above

Although liability under the anti-kickback statute ultimately turns on a party's intent, it is possible to identify arrangements or practices that may present a significant potential for abuse. Which question would be helpful to determine whether a proposed action could violate the anti-kickback statute? A. Does the arrangement or practice have a potential to improve clinical decision-making? B. Does the arrangement or practice have a potential to decrease costs to Federal health care programs, beneficiaries, or enrollees? C. Does the arrangement or practice have a potential to decrease the risk of overutilization or inappropriate utilization? D. Does the arrangement or practice raise patient safety or quality of care concerns?

D. Does the arrangement or practice raise patient safety or quality of care concerns?

Services furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are: A. Documented and co-signed by the teaching physician identifying that he/she agrees with the residents note as long as he/she personally reviewed the record and agreed with the resident. B. Furnished by a medical student when a teaching physician is providing direct supervision during the critical or key portions of the service. C. Furnished by a medical student under a primary care exception within an approved Graduate Medical Education (GME) Program as long as the teaching physician is providing direct supervision during the critical or key portions of the service. D. Personally furnished by a physician who is not a resident.

D. Personally furnished by a physician who is not a resident.

What is the most common type of laboratory? A. Independent laboratory B. Hospital laboratory C. Public health laboratory D. Physician office laboratory

D. Physician office laboratory

For larger physician practices, how frequently does the OIG recommend reporting compliance activities to the Board of Directors and CEO? A. Monthly B. Quarterly C. Annually D. Regularly

D. Regularly

A new orthopedic physician is being hired in a group practice. The group has been searching for quite a while and finally found the perfect candidate. As part of the practice's hiring process, employees must be checked against the OIG and GSA lists for excluded parties. Does this practice also apply to physicians? A. No, this requirement only applies to non-medical employees of the practice. B. No, this requirement only applies to non-medical employees of the practice and vendors. C. Yes, this requirement only applies to physicians. D. Yes, this requirement applies to physicians and employees of the practice.

D. Yes, this requirement applies to physicians and employees of the practice.

A physician practice hired a consultant to perform external audit services for their practice. After the consultant began working, the OIG and GSA lists were checked and it was found the consultant was excluded from participation. What steps should the practice take? A. Nothing. Because the consultant is not ordering, referring, or performing medical services, there is no problem. B. Report the consultant to the OIG for violating her exclusion status. C. Immediately ask the consultant to stop work. D. Contact legal counsel. E. Both C and D

E. Both C and D

1998

HHS OIG created the 1st compliance guidance document: Compliance Program Guidance for Hospitals for HH, Clinical Labs and 3rd Party Medical billing Companies.

1976

OIG was created to fight FWA in Medicare, Medicaid and more than 300 other HHS programs.

How many agencies oversee ERISA? One Two Three Four

Three

Kim, compliance officer at Apple Rural Health Center, explains to her staff that OSHA falls under what division of the government? a. DOL b. CMS c. DOJ d. OIG

a. DOL

Workers Compensation is part of the _________. a. DOL b. DOJ c. CMS d. OIG

a. DOL

Employers are required to maintain an equipment injury log. Which one of the following would not be included on the log? a. Employee's name involved with the device accident b. The type and brand of device involved in an accident c. Location of the incident d. Description of the incident

a. Employee's name involved with the device accident

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

a. HHS Office of Inspector General Rationale: The HHS OIG is the largest inspector general's office in the federal government, with approximately 1,600 workers dedicated to combating fraud, waste, and abuse.

Which is true regarding internet usage? a. Inform employees that internet usage is monitored b. Inform nurses that they can use physician's password for view only purpose c. Allow employees to use internet for any reason they deem fit d. Allow managers to know employees' passwords

a. Inform employees that internet usage is monitored

Exposure determination is made by which one of the following? a. Reviewing job classifications b. What personal protective equipment was used c. Whether cat litter was used to clean spill d. The location of the contact

a. Reviewing job classifications

Which regulation established the Medicaid Integrity Program? a. Section 1936 of the Social Security Act b. Affordable Care Act c. Medicare Modernization Act d. Health Insurance Portability and Accountability Act of 1996

a. Section 1936 of the Social Security Act

How many years should providers keep a record of disclosures? a. Six or more years b. Five years c. Four years d. Two years

a. Six or more years

OSHA encourages what foreign language in which to display the OSHA poster? a. Spanish b. German c. French d. As many languages as you need to meet the workers' needs

a. Spanish

The OIG has developed five principles as part of their strategy to promote integrity in the healthcare industry. Which of these statements are included in these principles? a. Vigilantly monitor programs for evidence of fraud, waste, and abuse. b. Establish compliance officers for each healthcare provider's office. c. Scrutinize compliance plans to ensure all compliance plans are uniform and unaltered. d. Respond swiftly to natural catastrophes.

a. Vigilantly monitor programs for evidence of fraud, waste, and abuse. Rationale: 1. Enrollment — Scrutinize individuals and entities that want to participate as providers and suppliers prior to their enrollment in healthcare programs. 2. Payment — Establish payment methodologies that are reasonable and responsive to changes in the marketplace. 3. Compliance — Assist healthcare providers and suppliers in adopting practices that promote compliance with program requirements, including quality and safety standards. 4. Oversight — Vigilantly monitor programs for evidence of fraud, waste, and abuse. 5. Response — Respond swiftly to detected fraud, impose sufficient punishment to deter others, and promptly remedy program vulnerabilities.

A certificate for provider performed microscopy (PPM) procedures is issued to a laboratory in which a physician, midlevel practitioner, or dentist performs no tests other than which of the following? a. Waived tests and PPM procedures b. Moderate complexity and PPM procedures c. High complexity and PPM procedures d. Pap smears

a. Waived tests and PPM procedures This certificate is issued to a laboratory in which a physician, midlevel practitioner, or dentist performs no tests other than PPM procedures. This certificate permits the laboratory to also perform waived tests.

Which of the following is NOT a requirement for MSDS sheets? a. What quantity the medical facility purchases yearly b. Spill and disposal procedures c. Personal protective equipment used d. Handling and storage precautions

a. What quantity the medical facility purchases yearly

When wouldn't a medical facility be required to have an ionizing radiation policy? a. When they do not have an X-ray machine b. When X-ray rooms need to have special labeling and equipment c. When caution signs are used to restrict access d. When they need to restrict areas to limit exposure

a. When they do not have an X-ray machine

Can a billing company offer marketing services to its clients? a. Yes, as long as remuneration is not involved. b. No, they need to only provide billing services. c. Yes, even if remuneration is involved. d. Not in certain states.

a. Yes, as long as remuneration is not involved.

Is it acceptable for practices to call and remind patients of their appointments? a. Yes, if it is stated in the Notice of Privacy Practices b. Yes, if the patient has signed a waiver giving the practice permission to call c. No, practices can no longer call and remind patients of their appointments d. Yes, but only if the reminder calls are between 6 p.m. and 8 p.m.

a. Yes, if it is stated in the Notice of Privacy Practices Rationale: Appointment reminders are considered part of treatment of an individual and, therefore, can be made without authorization.

Tim is the compliance officer for XYZ Billing. As the compliance officer for a billing company, should Tim also work with the provider's compliance officer the company bills for? a. Yes, the OIG recommends a billing company coordinate compliance functions with the provider's compliance officer. b. No, the OIG does not recommend a billing company coordinating compliance functions with the provider's offices. c. No, all compliance officers need to keep their information confidential. d. Yes, as long as a business associate agreement is signed.

a. Yes, the OIG recommends a billing company coordinate compliance functions with the provider's compliance officer.

Does a provider who is only performing waived tests need a CLIA number? a. Yes, the law requires that no matter what type of testing is performed, a CLIA number is required. b. No, waived testing does not require the provider to have a CLIA number. c. No, Medicare does not pay for waived testing. d. Yes, the law requires that no matter what type of testing is performed, only Medicare providers need a CLIA number.

a. Yes, the law requires that no matter what type of testing is performed, a CLIA number is required.

How many of the Medicaid Fraud Control Units are located as part of Offices of State Attorneys General? a. 43 b. 44 c. 49 d. 42

b. 44

Because it is such a large component of their responsibility, what percentage of resources does OIG dedicate to Medicare and Medicaid? a. 70 percent b. 80 percent c. 85 percent d. 90 percent

b. 80 percent

Which agency provides opinions on the Stark Law? a. OIG b. CMS c. MAC d. HHS

b. CMS

What type of software identifies potential claim errors? a. Certified Error Rate Testing (CERT) b. Data mining c. Fishing d. MACs

b. Data mining

Health information that does not identify an individual is called _______________. a. Cloned information b. De-identified information c. Re-identified information d. Misidentified information

b. De-identified information Rationale: Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.

John is the Compliance Officer for a small group provider office. He is in the process of designing and setting up a training program for the office. Per the OIG guidelines, what steps should John take? a. Not worry about it because all training needs to be unique. b. Determine who needs training; determine type of training, and determine when and how often the training/education should occur. c. Determine who needs training; determine type of training; and determine the least amount of time the training can be done to save on resources. d. Determine who does not need training to save on cost; determine type of training; and determine when and how often the training/education should occur.

b. Determine who needs training; determine type of training, and determine when and how often the training/education should occur. Rationale: The OIG considers education to be an important part of any compliance program. If risk areas are identified, it makes sense to educate clinicians and staff of correct procedures. The OIG recognizes that education programs will be tailored to the physician practice's needs, specialty, and size, and will include both compliance and specific training.The OIG outlines three basic steps for setting up educational objectives: 1. Determine who needs training (both in coding/billing and in compliance). 2. Determine the type of training that best suits the practice's needs (for example, seminars, in-service training, self-study, or other programs). 3. Determine when and how often education is needed and how much each person should receive.

LCDs and NCDs provide information for coverage limited to certain what? a. CPT® codes b. Diagnosis codes c. HCPCS Level II codes d. Inpatient codes

b. Diagnosis codes Rationale: LCDs and NCDs provide information for coverage limited to certain diagnoses. Coverage decisions may limit the frequency of an item or service or deny an item or service outright as experimental and non-covered. Private payers may follow CMS' NCDs or they may have their own LCDs.

Why should compliance officers have set disciplinary policies for non-compliance? a. Employees need rules to follow. b. Employees should know the consequences for non-compliance of set policies. c. Employees should know what is expected of them. d. Employees need to understand policies set in place.

b. Employees should know the consequences for non-compliance of set policies. Rationale: There should be clear communication of what is expected of employees and equally clear communication of the consequences for not following written policies.

Tim is the compliance officer for the Apple Internal Medicine Group. He conducts the in-service training for all new employees. What are the five most important federal fraud and abuse laws he should discuss? a. ACA, OIG, CMS, ACO, FCA b. FCA, AKS, Stark, Exclusion, CMPL c. FCA, AKS, Stark, CMPL, OIG d. Stark, AKS, Exclusion, FCA, OIG

b. FCA, AKS, Stark, Exclusion, CMPL

CMS publishes the physician fee schedule each year in the _____. a. Work Plan b. Federal Register c. Semi Annual Report d. Advisory Letters

b. Federal Register

Which of the following should be reflected in a billing company's written policies and procedures? a. Current Federal statutes only b. Current Federal and state statutes c. Current regional and Federal statutes d. Current state statutes only

b. Federal and state statutes Rationale: With respect to claims, a billing company's written policies and procedures should reflect and reinforce current federal and state statutes.

CMS is a division of _________. a. MAC b. HHS c. OIG d. HIPAA

b. HHS

Which agency does NOT have a role in assuring laboratory testing for CLIA? a. CDC b. HHS c. CMS d. FDA

b. HHS

Most corporate integrity agreements require an IRO. What does this acronym stand for? a. Independent Revenue Organization (IRO) b. Independent Review Organization (IRO) c. Independent Reorganization Organization (IRO) d. Independent Recall Organization (IRO)

b. Independent Review Organization (IRO)

What is an OSHA 300 form used for? a. It provides the employer a safety rating. b. It provides a total number of job-related injuries for the year. c. It is a form used only by hospitals to indicate job-related injuries for the year. d. It provides the medical facility with an exposure control plan.

b. It provides a total number of job-related injuries for the year.

What is a key concept of the Privacy Rule? a. Training b. Minimum necessary c. Communication d. Notice of Privacy Practices

b. Minimum necessary Rationale: The concept of "minimum necessary" is central to the Privacy Rule and means to use or disclose the minimum amount of PHI needed for the intended purpose.

After hiring, how often should providers check to make sure employees are not on the OIG List of Excluded Individuals? a. Annually b. Monthly c. Quarterly d. Once every 10 years

b. Monthly

Which agency provides advisory opinions providing meaningful advice on the application of the Anti-Kickback Statute? a. HHS b. OIG c. MAC d. CMS

b. OIG

Which entity reviews and certifies each MFCU every year, and monitors whether they are complying with statutes, regulations, and its policies? a. DOJ b. OIG c. OCR d. CMS

b. OIG

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

b. OIG's Clinical Lab Guidance Rationale: The OIG Clinical Lab Guidance provides pertinent information on effective compliance and risk areas for laboratories.

Which Medicare part plan contains fraud and abuse prohibitions? a. Part C b. Part E c. Part A d. Part B

b. Part E

Which serves as a reference source of information about personnel policies and procedures? a. Nursing handbook b. Personnel policy manual c. Physician desk reference d. Material safety data sheets

b. Personnel policy manual

What can MFCU only do if there is a conspiracy with a provider? a. Arrest a provider b. Pursue recipient fraud c. Place a provider on administrative leave of absence d. Show up unannounced at a provider's practice

b. Pursue recipient fraud

Civil actions may be brought in federal district court under the False Claims Act by the Attorney General, or by a person known as a relator, in what type of action? a. Antitrust b. Qui tam c. Disciplinary d. Evidence based

b. Qui tam

Which law increases the severity of penalties for violations involving organized crime? a. Deficit Reduction Act b. Racketeer Influenced and Corrupt Organization Act c. Medicare Modernization Act d. Fraud Enforcement and Recovery Act

b. Racketeer Influenced and Corrupt Organization Act

What is required for a compliance program to be effective? a. The compliance program needs to be reviewed daily for any compliance updates. b. Regularly review and update the compliance program. c. The compliance program must be reviewed by healthcare lawyers. d. The compliance program needs to be reviewed weekly for any compliance updates.

b. Regularly review and update the compliance program. Rationale: Simply implementing a compliance program is not enough. It will need to be reviewed and updated on a regular basis.

Dr. X at XYZ Family Practice Group wants to know if he can accept gifts. Providers can give physicians gifts and other benefits up to a set amount each year, adjusted for inflation. Gifts and benefits should be tracked: If the set amount is exceeded, what can the physician do? a. Offset the balance for the next year. b. Repay the excess. c. Keep the money because no one is enforcing the rule. d. Donate the excess to charity.

b. Repay the excess.

Implementing an effective compliance program significantly reduces what? a. Regulations b. Risk c. Incidents d. Audits

b. Risk

Waived and PPM laboratories may apply directly for their certificate as they are not subject to what? a. Sanctions b. Routine inspections c. Waiting periods d. Surveys

b. Routine inspections

How many elements are required to have a successful compliance program? a. Five b. Seven c. Eight d. Nine

b. Seven Rationale: The OIG guidance documents the seven elements of the Federal Sentencing Guidelines as the basis of an effective compliance program.

If physician recruitment arrangements are not properly structured it can result in which one of the following? a. False Claim Act violations b. Significant fines and penalties c. Malpractice insurance hikes d. EMTALA violations

b. Significant fines and penalties

To help curb abusive and fraudulent practices in DME companies, a Certificate of Medical Necessity (CMN) is required for certain services. Which action can lead to criminal, civil, and administrative penalties? a. A supplier waiting until a CMN is on file before a claim is submitted to Medicare b. Signing a blank CMN c. Having a different date for the initial date and the signature date d. The physician completing sections B and D of the CM

b. Signing a blank CMN Some services — in particular, Medicare-covered DME — require physicians to complete a Certificate of Medical Necessity (CMN). The CMN requirement is intended to curb abusive and fraudulent DME companies. Activities such as signing blank CMNs, signing a CMN without seeing the patient to verify the item or service is reasonable and necessary, and signing a CMN for a service that the physician knows is not reasonable and necessary are activities that can lead to criminal, civil, and administrative penalties.

Which one of the employees does NOT fall under Category I in being at risk for occupational exposure to bloodborne pathogens? a. Imaging services technologists b. Social workers c. Laboratory - all personnel d. Respiratory therapy personnel

b. Social workers

What is published to address compliance concerns, such as compensation paid by laboratories to referring physicians and physician group practices for blood specimen collection, processing, packaging and for submitting patient data to registry or database? a. Code alerts b. Special fraud alerts c. The anti-kickback statute d. The Stark law

b. Special fraud alerts The OIG has issued special fraud alerts to the healthcare provider community for the last 20 years. Fraud alerts were originally for internal use only between the HHS organizations, but in 1994, the OIG began releasing the information to the healthcare provider community and later to the public. The reason for developing and dispersing the fraud alerts include: (1) to inform other HHS agencies and investigators of fraudulent and abusive practices within the healthcare industry; (2) to inform the healthcare industry and the general public of fraudulent and abusive practices within the healthcare industry; and (3) to inform the healthcare industry and general public of how and where to report information about suspected fraudulent and abusive practices.

What sets UPIC audits apart from other Medicare audits? a. The audits are done alphabetically by region. b. The audits are targeted by potential Medicare fraud. c. The audits are performed nationwide. d. The audits are performed in regions.

b. The audits are targeted by potential Medicare fraud

How many states require nursing facilities to perform a FBI checks on employees? a. 3 b. 5 c. 10 d. 27

c. 10 Rationale: Out of 50 states, 10 states have mandated nursing homes perform an FBI background checks on employees.

How does a GFCI function? a. It stops water from touching the electrical outlet. b. It protects the electrical outlet from water splashes. c. It will shut off in the event of a ground fault. d. It will stop any electrical shock

c. It will shut off in the event of a ground fault.

The highest E/M level that can be reported for a resident on their own and discuss the case with the teaching physician is what level? a. Level 1 b. Level 2 c. Level 3 d. Level 4

c. Level 3

What is an essential component for the lawful behavior and success of nursing facilities? a. OIG oversight b. Federal nursing boards c. Quality of care d. None of the above

c. Quality of care

Which regulation, identified in the OPPS final rule, requires hospitals to include all OPPS services provided at the same hospital to the same patient, on the same day, on the same claim, unless certain conditions are met? a. Incident-to rule b. Anti-kickback rule c. Same-day rule d. DRG creep

c. Same-day rule

John is the compliance officer for the ABC Internal Medicine Group. His board of directors wants to know what the final compliance date was for the HIPAA Omnibus Rule that made it mandatory to report ALL breaches if there was a risk to the patient. John's reply should be what date? a. March 2009 b. January 2011 c. September 2013 d. December 2008

c. September 2013

Improper advertising can get the physician in trouble with whom? a. Attorney general b. OIG c. The state licensing board d. CMS

c. The state licensing board

Under EMTALA, a treating physician can consult other physicians in what ways? a. Telephone b. Video conferencing c. Internet d. All of the above

d. All of the above

What are designated health services? a. Clinical laboratory services b. Physical therapy services c. Home health services d. All of the above

d. All of the above

What rule sets limits with PHI? a. The Safeguard Rule b. The PHI Rule c. The Technical Rule d. The Privacy Rule

d. The Privacy Rule

Which one of the following is a relator? a. The provider who makes the complaint b. The OIG agent that intervenes c. The hospital where the complaint is made d. The whistleblower

d. The whistleblower

The DOJ consists of numerous agencies, including:

the Federal Bureau of Investigation (FBI) and the Drug Enforcement Administration (DEA). A list of all the agencies can be found at https://www.justice.gov/agencies/chart.

The OIG consists of 6 departments:

1.Immediate OIG — responsible for the overall fulfillment of the OIG's mission and for promoting effective management and quality of the agency's processes and products. 2.Office of Audit Services — performs independent audits of HHS programs and/or HHS grantees and contractors to examine their performance. 3.Office of Evaluation and Inspections — conducts national evaluations of HHS programs from a broad issue-based perspective. 4.Office of Management and Policy — provides mission and administrative support to the OIG. 5.Office of Investigations (OI) — conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. The OI also operates an OIG hotline. 6.Office of Counsel to the Inspector General — provides legal advocacy and counsel to the Inspector General and OIG's other components.

Hospital compliance guidance was published by the OIG in February 1998. When was the supplemental compliance guidance for hospitals published? 2005 2006 2008 2010

2005

The nationwide network of MACs dates back to ____________. a. 1996 b. 2002 c. 2001 d. 2006

d. 2006

According to the Federal Register, the OIG has listed a number of potential risk areas for physician practices. These risk areas include: (a) coding and billing, (b) reasonable and necessary services, and (c) documentation.Which scenario is considered a risk area or areas for a physician practice? A. Dr. Y bills Medicare using a covered office visit code when the actual service was a non-covered annual physical. This could be considered improper coding or billing and therefore is considered a risk area. B. Dr. X bills Medicare using a CPT® surgical code including dressings and instruments for a minor procedure in which dressings and instruments are included in a single fee. This could be considered improper coding or billing and therefore is considered a risk area. C. Dr. Z bills Medicare for a preventive medicine service code when the actual service was a non-covered annual physical. This could be considered improper coding or billing and therefore is considered a risk area. D. Dr. T bills Medicare with a modifier, as defined by the CPT® codebook, to indicate that a service or procedure which has been performed has been altered. This could be considered improper coding or billing and therefore is considered a risk area.

A. Dr. Y bills Medicare using a covered office visit code when the actual service was a non-covered annual physical. This could be considered improper coding or billing and therefore is considered a risk area. To assist physician practices in performing this initial assessment, the OIG has developed a list of four potential risk areas affecting physician practices. These risk areas include: (a) Coding and billing; (b) reasonable and necessary services; (c) documentation; "Although duplicate billing can occur due to simple error, the knowing submission of duplicate claims—which is sometimes evidenced by • Billing for non-covered services as if covered; • Knowing misuse of provider identification numbers, which results in improper billing; • Unbundling (billing for each component of the service instead of billing or using an all-inclusive code); • Failure to properly use coding modifiers; • Clustering; and • Upcoding the level of service provided.

Which setting is the incident-to rule NOT applicable? A. Hospital B. Solo-Physician office C. Group Practice D. Multi-Disciplinary Group Practice

A. Hospital

Any health care fraud scheme that disseminate any article or document through a "common mail carrier" may be the basis for a charge of: A. Mail Fraud B. Wire Fraud C. Mail Fraud and Wire Fraud D. False Claims

A. Mail Fraud

According to the Federal Sentencing Guidelines, "To have an effective compliance and ethics program..., an organization shall exercise due diligence to prevent and detect criminal conduct." The FSGs also state organizations shall: A. Promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law. B. Implement mandatory compliance programs. C. Perform annual audits to detect criminal conduct. D. Immediately report evidence of misconduct to the authorities.

A. Promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.

What does the HHS OIG suggest as possible warning signs that non-compliance may exist? A. Significant change in the number or type of claim rejections. B. Getting carrier newsletters pertaining to the types of service that your practice bills. C. Consistent use of certain codes. D. Receipt of carrier requests for documentation.

A. Significant change in the number or type of claim rejections.

As part of a practice's compliance program, record retention policies and procedures should be developed. This policy and procedure should address the timeframes associated with the retention of various records. When developing a policy, which of the following statements should be present? A. Specific records must be retained based upon the most stringent requirement identified in federal or state law, or internal policies and procedures. B. Records will be retained based upon federal requirements as this supersedes state law or internal policies/procedures. C. Records will be retained based upon state requirements as this supersedes federal law or internal policies/procedures. D. Records will be retained based upon internal policies/procedures as this supersedes both federal and state laws.

A. Specific records must be retained based upon the most stringent requirement identified in federal or state law, or internal policies and procedures.

CMS' Self-Referral Disclosure Protocol (SRDP) sets forth a process for providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute (section 1877 of the Social Security Act). Which statement is TRUE about the SRDP? A. The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party's reasonable assessment are actual or potential violations of the physician self-referral statute. B. Participation in the SRDP is only limited to physicians. C. Disclosing parties can disclose the same conduct under both the SRDP and the OIG's Self-Disclosure Protocol. D. To facilitate CMS' verification and validation processes, CMS requires access to all financial statements, notes, disclosures and other supporting documents regardless of the assertion of privileges or limitations on the information produced.

A. The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party's reasonable assessment are actual or potential violations of the physician self-referral statute.

When agreeing to a global civil fraud settlement, what is the most popular reason why a provider agrees to enter into a Corporate Integrity Agreement? A. To avoid exclusion from participation in Federal health care programs B. To obtain a Civil Monetary Penalty reduction C. To obtain a fine reduction D. To avoid incarceration

A. To avoid exclusion from participation in Federal health care programs

A physician office laboratory is authorized to perform urinalysis testing, including the microscopic analysis under their Provider-Performed Microscopy Procedures (PPMP) certification. It has been the physician's experience that many of his patients that have urinalysis testing done also requires the microscopic exam. Because of this and to be able to provide better treatment, he has established an office policy that for all urinalysis testing performed in his office, the lab should also perform the microscopic test. Is this a compliance risk? A. Yes. Performing the microscopic test on all patients when the results of the urinalysis are negative could be considered medically unnecessary. B. Yes. The physician must always order the code for the urinalysis test with the microscopic exam to avoid unbundling. C. No. Because the physician is providing quality patient care, there is no compliance risk. D. No. The physician is performing tests that are authorized under his CLIA certification so there is no compliance risk.

A. Yes. Performing the microscopic test on all patients when the results of the urinalysis are negative could be considered medically unnecessary.

According to CLIA, personnel performing waived tests must: A. Be trained to perform the tests, such as through on-the-job training. B. Carefully follow the manufacturer's instructions when performing tests. C. Hold at least an Associate's Degree in a health care related field. D. Undergo annual proficiency testing.

B. Carefully follow the manufacturer's instructions when performing tests.

Having the ability to respond to issues enables a practice to develop effective action plans to correct problems and prevent future problems from occurring. What is one step that can be taken to establish compliance effectiveness for responding to and/or preventing compliance issues? A. Create a response team, consisting of representatives from the compliance and audit department. B. Create a response team, consisting of representatives from compliance, audit, and any other relevant functional department. C. Create an investigation team, consisting of representatives from compliance, audit, and any other relevant functional department. D. Create a prevention team, consisting of representatives from compliance, audit, and any other relevant functional department.

B. Create a response team, consisting of representatives from compliance, audit, and any other relevant functional department.

As the compliance contact for your physician practice, you are charged with developing the policies and procedures related to coding and billing. When developing these policies and procedures, which of the following statements should be included? A. If a new physician joins the practice and the new physician's NPI has not been received, services performed should be reported using the practice medical director's NPI. B. For any services billed, documentation must be present in the patient's medical record to support the services. C. To avoid compliance risk, coding for E/M services should be based solely on medical record documentation, even if it appears the level of service is not warranted. D. For denied services, billing staff should notify the physician to change the reported diagnosis to allow for resubmission and payment of the claim.

B. For any services billed, documentation must be present in the patient's medical record to support the services.

An office manager has misplaced his laptop. The hard drive on the laptop is not encrypted. Which of the following data stored on the laptop would be considered a HIPAA breach if someone gains access to the laptop? A. Employee immunization records B. Medicaid Reports listing patient names and dates of birth. C. Physician schedules for the operating room listing the physician's name and procedure done D. Health records of students

B. Medicaid Reports listing patient names and dates of birth.

Dr. Amber is the emergency department physician at Orangevale Hospital. A patient arrives complaining of chest pains, dizziness, and shortness of breath for the past three hours. What is the first thing Dr. Amber must do to comply with EMTALA? A. Make sure the patient has been properly registered with the hospital so they can begin pre-authorizing services. B. Provide a medical screening examination to determine if the patient has a medical emergency. C. Provide a medical screening examination to determine where the patient should be transferred. D. Immediately transfer the patient to Heart Hospital because they have a much better cardiac care program.

B. Provide a medical screening examination to determine if the patient has a medical emergency.

If a physician practice uses another entity's standards of conduct, the practice must: A. Implement the standards of conduct as received because they have already been approved. B. Tailor those materials to the physician practice where they will be applied. C. Only select those standards that represent high risk issues for the practice. D. None of the above. Physician practices must create their own standards of conduct. It would be a compliance violation to copy another entity's standards of conduct.

B. Tailor those materials to the physician practice where they will be applied.

According to the OIG, medically unnecessary services should only be billed to Medicare in what circumstance? A. When directed to do so by the patient under ABN rules. B. To receive a denial so that the claim can be submitted to a secondary payer. C. When the provider is willing to submit the documentation to support the need for the service even though it is likely that Medicare will deny in any event. D. They should always be reported provided that an appropriate modifier is used to signal that the services are not medically necessary and should not be covered.

B. To receive a denial so that the claim can be submitted to a secondary payer.

When is a covered entity required to provide the patient with a copy of the notice of privacy practices? A. They are only required to post it in their office and do not have to give the patient a copy. B. Any time the patient comes to the office and the staff remembers to give them one. C. At the first services encounter by personal delivery and obtain a written acknowledgement. D. They are only required to post the notice of privacy practices on their website.

C. At the first services encounter by personal delivery and obtain a written acknowledgement.

Dr. Appleton is an orthopedic surgeon in a large orthopedic practice. Due to the success of their clinic, the practice is opening a new orthopedic hospital that will be owned by all of the physicians in the group. In addition to Stark Law issues, what other compliance concern may be present? A. Dr. Appleton's referral of patients to the orthopedic hospital will violate the False Claims Act and subject him to the associated penalties and fines. B. Dr. Appleton and his colleagues will be paid a set amount of the profits, regardless of the value or volume of referrals. C. Dr. Appleton's ownership in the orthopedic hospital represents a conflict of interest because his decisions on the care needed by his patients may be biased by his potential financial gain for referring patients to the facility. D. There is no compliance concern. By opening a new orthopedic hospital, the practice is helping to assure needed orthopedic care to the community.

C. Dr. Appleton's ownership in the orthopedic hospital represents a conflict of interest because his decisions on the care needed by his patients may be biased by his potential financial gain for referring patients to the facility.

Physician Quack just completed a 15-minute psychiatric evaluation of his patient. He intentionally completes his superbill for a 30-45-minute session. Dr. Quack may be liable for: A. Abuse B. Neglect C. Fraud D. None of the above

C. Fraud

A patient being seen by a physician has unpaid medical bills in excess of $5,000 after insurance payments. The patient has now lost his job and has limited financial resources. The office manager has reviewed the patient's financial situation to assess the patient's ability to pay and has agreed to reduce the fees owed to $2,500. Would this act violate the OIG gift allowance for beneficiaries? A. Yes, the OIG gift allowance must be followed, even if a patient is unable to pay. B. Yes, by discounting the price to the patient, the practice must now increase fees to other payers, including Medicare, to make up the difference which is not allowed. C. No, this would be an exception to the OIG gift allowance because it is based on the patient's ability to pay. D. No, as long as the practice spreads out the fee reduction over more than one year.

C. No, this would be an exception to the OIG gift allowance because it is based on the patient's ability to pay.

What is the goal of ongoing auditing and monitoring in a physician's practice? A. Ongoing auditing and monitoring will prevent fraud B. Ongoing auditing and monitoring will enhance revenues by detecting instances of undercoding. C. Ongoing auditing and monitoring will evaluate whether the physician practice's standards and procedures are current and accurate and whether the compliance program is working. D. Ongoing auditing and monitoring will improve the quality of patient care.

C. Ongoing auditing and monitoring will evaluate whether the physician practice's standards and procedures are current and accurate and whether the compliance program is working.

The Federal Anti-Kickback Statute places certain constraints on business arrangements related directly or indirectly to items or services reimbursed by any Federal health care program, including, but not limited to, Medicare and Medicaid. According to the OIG, which of the following would likely be an acceptable practice? A. A physician practice should participate in all aspects of a hospital's compliance program to be sure the anti-kickback statute is not violated. B. The hospital should oversee the physician practice's compliance program at no cost for the physicians in exchange for timely and accurate completion of inpatient records. C. The physician practice should limit participation in a hospital's compliance program to training and education or policies and procedures only. D. A hospital performs an annual claim audit for its affiliated physician practices. There is no charge for the audit as the hospital includes this as part of its annual compliance program.

C. The physician practice should limit participation in a hospital's compliance program to training and education or policies and procedures only.

Select the best phrase from the list below to complete the following policy statement: Centennial Medical Associates is committed to following Federal, State, and Local laws, rules, guidelines, and regulations. To promote this effort, Centennial Medical Associates will perform claims audits at least on an annual basis to ____________________. A. Maximize reimbursement for the services performed. B. Optimize reimbursement for the services performed. C. Verify accuracy of coding and reimbursement for the services performed. D. Ensure all services are submitted for reimbursement.

C. Verify accuracy of coding and reimbursement for the services performed.

Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), is also known as the physician self-referral law and commonly referred to as the "Stark Law". The Stark Law applies to which of the following individuals or entities? A. Patients and their families B. Physicians and hospitals C. Federal health care programs like Medicare D. Both B and C

D. Both B and C

City Orthopedics, a large physician group practice employs several physician assistants and nurse practitioners. There have been several questions by the physicians on how incident to services should be billed. The compliance officer has called the Medicare Administrative Contractor for the practice and was given some information on how incident to services should be billed. Because the practice will be relying on the information received from the Medicare Administrative Contractor, what steps should the compliance officer take at the conclusion of the call according to the OIG Compliance Guidance for Individual and Small Group Physician Practices? A. Call someone else at the Medicare Administrative Contractor to confirm the information received. B. Send a letter to CMS to confirm the information provided by the Medicare Administrative Contractor is correct. C. Both A and B D. Document the conversation and retain the records.

D. Document the conversation and retain the records.

Which entity provides benefit integrity investigations based on billing abnormalities identified by data analysis or allegations of fraud and abuse, as well as conducts reviews that will allow them to compare billing of Medicare claims to Medicaid claims known as the "Medi-Medi" program that helps to identify fraudulent activity between the two programs? A. Medi-Medi Audit Contractors (MACs) B. Recovery Audit Contractors (RACs) C. Medicaid Integrity Contractors (MICs) D. Unified Program Integrity Contractors (UPICs)

D. Unified Program Integrity Contractors (UPICs)

According the Social Security Act, Sec. 1877. [42 U.S.C. 1395], prohibitions on certain referral arrangements include those that involve financial arrangements between entities and physician practices. In the law, rental of office space is considered not to be a compensation arrangement under certain conditions and as such are considered exceptions as long as which of the following exists? A. The lease would be commercially reasonable even if no referrals were made between the parties and has a term or rental or lease for at least one 1 year. B. The lease provides for a term of rental or lease for at least 1 year C. The space rented or leased does not exceed that which is reasonable and necessary for the legitimate business purposes of the lease or rental and is used exclusively by the lessee when being used by the lessee D. The rental charges over the term of the lease are set in advance, are consistent with fair market value, and are not determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties E. All of the above

E. All of the above

2010

Patient Protection & Affordable Care Act (PPACA), AKA Obamacare was created. Health Care Education Reconciliation Act which is AKA Healthcare Reform Law.

What is HHS OCR (Office of Civil Rights)?

Responsible to enforce the HIPAA Privacy Rule and Security Rule provisions. The Civil Rights Act of 1964 as it applies to limited English proficiency (see below), the confidentiality provisions of the Patient Safety Act and Rule, the Church Amendments, section 245 of the Public Health Service Act, and the Weldon Amendment.

2005

Supplemental Guidance Program Guidance for Hospitals.

What are CIA (Corporate Integrity Agreements)?

Used to enforce compliance within a healthcare organization. Used as a part of a civil settlement with a provider or organization when there has been an investigation into the claims submitted to a federal payer. I

In what timeframe is an employer required to post the OSHA 300? a. Between February 1 and April 30 b. Between January 1 and December 30 c. Between January and December d. Between February and March

a. Between February 1 and April 30

According to the OIG, which of the following is an option for designating a compliance officer? a. A compliance committee can be formed to perform the compliance duties with a specified person ultimately responsible for coordination and completion. b. The OIG requires one person to be designated as a Compliance Officer so they have one point of contact for each organization. c. The OIG requires a Compliance Officer to only be committed to one entity. d. It is understood that everyone in an office is responsible for compliance, so it is not required to specify a compliance officer.

a. A compliance committee can be formed to perform the compliance duties with a specified person ultimately responsible for coordination and completion. OIG compliance guidance recommends that an employee take on designated compliance responsibility, but recognizes that it may be difficult for a practice to designate one person to oversee compliance functions. Multiple people within the organization can perform compliance duties with the compliance officer, with the employee ultimately responsible for coordination and completion. This group of people becomes part of the organization's Compliance Committee.

What is considered an appropriate start to implementing an effective compliance program for compliance officers of small physician group practices with limited resources? a. Adopt only those components which, based on the practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit. b. A compliance program will not be effective unless every element is fully implemented. c. Have a manual of policies and procedures available for review in the manager's office. d. Small practices are low-risk so they do not need to implement a compliance program.

a. Adopt only those components which, based on the practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit. Rationale: The OIG acknowledges that full implementation of all components may not be feasible for all physician practices. Some physician practices may never fully implement all of the components. However, as a first step, physician practices can begin by adopting only those components which, based on a practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit.

In addition to working with law enforcement partners to sanction companies and individuals who violate the law, the OIG also commits substantial resources to promote voluntary compliance by the healthcare industry. In what form do they provide guidance to the healthcare industry? a. Advisory opinions, special fraud alerts, special advisory bulletins, compliance program guidance b. Advisory opinions, special fraud alerts, special advisory bulletins, legal counsel c. Advisory opinions, special fraud alerts, special advisory bulletins, IRO selection d. Advisory opinions, special fraud alerts special advisory bulletins, free hotline service for non-exempt employees

a. Advisory opinions, special fraud alerts, special advisory bulletins, compliance program guidance

What does the 250-yard zone rule NOT apply to? a. All hospital-owned physician practices b. The main entrance of the hospital c. The emergency department d. The parking lot

a. All hospital-owned physician practices

In 1992, the General Accounting Office (GAO) identified Medicare claims to be at high risk for fraud and abuse(GAO/ HR-93-6, Dec. 1992). Subsequent to this determination, in 1996, what was initiated? a. An audit of HCFA (CMS) Medicare claims payment system. b. OIG compliance program documents for each provider type. c. The creation of evaluation and management documentation guidelines. d. The creation of corporate integrity agreements.

a. An audit of HCFA (CMS) Medicare claims payment system. Rationale: In 1992, the General Accounting Office (GAO) identified Medicare claims to be at high risk for fraud and abuse. (GAO/HR-93-6, Dec. 1992). Subsequent to this determination, in 1996, the OIG initiated an audit of the Health Care Finance Administration (later renamed Centers for Medicare & Medicaid Services [CMS]) Medicare claims payment system.

Routine waiver of Medicare deductibles or copayments is a violation of which statute/law? a. Anti-kickback b. Civil monetary penalties c. False Claims Act d. Stark II

a. Anti-kickback Rationale: Patient discounts that involve the provision of services at no charge, or the waiver of a patient's copayment or deductible, may raise concerns under the federal anti-kickback statute (AKS). The OIG has stated that routine waivers of Part B service copayments for federal program beneficiaries may violate the AKS.

XYZ Family Practice Group is renting space from the local hospital that owns rental property. A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital is in violation of which regulation? a. Anti-kickback statute b. False Claims Act c. Qui tam provisions d. Stark law

a. Anti-kickback statute Examples of the Anti-kickback statute violations: • A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital • Routine waiver of copayments or deductibles for patients under Medicare Part B • A drug or equipment supplier providing free benefits for a provider who uses their product • A physician who is paid large amounts for speaking engagements by a company whom the provider refers business to

Tim at XYZ wants to conduct a baseline audit. What will the baseline audit help determine? a. Areas of the billing department that might or might not comply. b. Areas of error in a federal health department only. c. Issues identified in the IT department related to compliance. d. Errors in operations.

a. Areas of the billing department that might or might not comply.

Attorney-client privilege protects communications that you have with your attorney and also which of the following? a. Attorney-client work-product b. Reports and memos only c. Is a guarantee of non-disclosure of information d. Is required when you have a compliance program

a. Attorney-client work-product Rationale: Attorney-client privilege protects communications that you have with your attorney. It derives from our Fifth Amendment right to not incriminate ourselves and is a long-established court rule for protecting both oral and written communications. An additional privilege applies to the work the attorney does in creating reports, interview memos, or research that is called attorney-client work-product.

An initial review of all areas of possible non-compliance within the practice/organization is necessary to reveal what areas of the practice/organization are currently in compliance with, and which areas they are not. This assessment is called what? a. Baseline b. Incident tracking c. Periodic d. Auditing and monitoring

a. Baseline

What third party plays a critical role in accurate billing and reimbursement? a. Billing agencies b. Laboratories c. Nursing facilities d. Office of Inspector General (OIG)

a. Billing agencies Rationale: Providers have come to rely on billing agencies over the years to send out correct claims on their behalf.

Some of the largest breaches reported to HHS involved ________________. a. Business associates b. Doctors c. Legal departments d. Nurses or other ancillary staff

a. Business associates

Once a vulnerability or risk has been identified, it is important to determine the risk rating. How is this determined? a. By the likelihood or probability of occurrence and the severity of impact b. By the rate of occurrence and the severity of impact c. By the possibility of occurrence and the severity of impact d. By the history of occurrence and the severity of impact

a. By the likelihood or probability of occurrence and the severity of impact

Most state programs now refer to the children's Medicaid program as _____. a. CHIP b. KIPP c. SNIP d. UPIC

a. CHIP

Who publishes the CLIA rules and regulations? a. CMS b. OIG c. The Lab Register d. HHS

a. CMS

Which President signed the Family Medical Leave Act (FMLA)? a. Clinton b. Obama c. Carter d. Bush

a. Clinton

What is the practice of coding/charging one or two mid-level service codes exclusively, such as billing only E/M levels 99213 and 99214 regardless of the services performed for the established patient, based on the philosophy that the charges will average out over an extended period? a. Clustering b. Upcoding c. Unbundling d. Down coding

a. Clustering

The compliance officer for ABC Medical Group is implementing a compliance training program. What must she do to track employee attendance? a. Complete a training log with the employee signatures and the trainer's signature to be placed in the employee's human resource file. b. Document the time and date of all training. Who attended is not required. c. Require each attendee to take a final quiz at the end of the training with a minimum score of 70% required. d. Have the provider of the training keep track of attendance in case it is required.

a. Complete a training log with the employee signatures and the trainer's signature to be placed in the employee's human resource file. Rationale: If updates to the standards and procedures are necessary, employees must be told as soon as possible. The OIG guidance recommends new employees be trained in standards and procedures as soon as possible as part of their orientation to the practice (occurring at or near the date of hire). It is essential that all training should be documented in the employee's human resources file. Verification with the employee (sign-in sheet) and supervisor's/trainer's signature should be part of the record. These training logs will also serve as attestation of compliance training that is required by some payers.

Which statement is TRUE regarding a corporate compliance plan? a. Compliance plans need to be tailored to fit the unique needs of every organization or physician practice. b. Everyone must follow the same rules and have the same policies and procedures in place. c. Compliance plans have a minimum cost to meet so the smaller practices can participate. d. The government wants to ensure that everyone budgets for compliance plans and has the same regulations and protocols.

a. Compliance plans need to be tailored to fit the unique needs of every organization or physician practice. Rationale: Compliance professionals need to be creative when implementing their entity's compliance program. The compliance program needs to be tailor-fit to the needs of the individual practice or healthcare organization. The OIG has stated that an effective compliance program can help create financial success, customer loyalty, community support, and employee satisfaction.

John is the compliance officer for ABC Medical Group. If one of the providers ask John the meaning of the acronym CERT, how should he reply? a. Comprehensive Error Rate Testing b. Certified Error Rate Technology c. Comprehensive Error Rate Technology d. Certified Entry Rate Technology

a. Comprehensive Error Rate Testing

Which of the following is NOT a purpose of the requisition lab slip? a. Contain a statement that indicates Medicare generally covers all routine screening tests b. Capture the correct program information c. Encourage physicians or other authorized individuals to submit the diagnosis information for all tests ordered d. Ensure the physician or other authorized individual has made an independent medical necessity decision with regard to each test the organization will bill

a. Contain a statement that indicates Medicare generally covers all routine screening tests

Failure to maintain a compliance program can expose the entity to government prosecution in the event it is subjected to what? a. Corporate Integrity Agreements b. Third Party Billing Agreements c. Federal Sentencing Guidelines d. Improper Inducements

a. Corporate Integrity Agreements Rationale: A voluntary compliance program indicates the entity's good faith effort to comply with all applicable laws and regulations. Failure to maintain a compliance program can expose the entity to government prosecution in the event it is subjected to a corporate integrity agreement (CIA).

The compliance officer is responsible to find areas of non-compliance and then formulate solutions to rectify the problems. This is known as a what? a. Corrective action plan b. Incident reporting plan c. Audit action plan d. Action reporting plan

a. Corrective action plan

Which of these responsibilities is NOT one of a compliance officer? a. Create all policies and procedures b. Ensure internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct c. Monitor the performance of the practice's compliance program on an ongoing basis, taking appropriate steps to improve its effectiveness d. Identify and assess areas of compliance risk for the practice

a. Create all policies and procedures

The compliance officer at Apple Internal Medicine Group explains to the board that there is a difference between the False Claims Act (FCA) Civil and criminal law. What is the difference between them? a. Criminal states that proof must be beyond a reasonable doubt. b. Coding mistakes are fined under civil but not criminal. c. Civil and civil monetary penalties work together. Criminal FCA does not work with civil monetary penalties. d. Civil involves fines as a penalty. Criminal involves jail time only.

a. Criminal states that proof must be beyond a reasonable doubt.

Which act provides a financial incentive for states to enact false claims acts that establish liability to the state for the submission of false or fraudulent claims to the state's Medicaid program? a. Deficit Reduction Act of 2005 b. Racketeer Influenced and Corrupt Organization Act c. Medicare Modernization Act of 2003 d. Fraud and Abuse Recovery Act of 2009

a. Deficit Reduction Act of 2005 DEFRA provides a financial incentive for states to enact false claims acts that establish liability to the state for the submission of false or fraudulent claims to the state's Medicaid program. If a state FCA is determined to meet certain requirements, the state is entitled to receive a greater monetary recovery with respect to any amounts recovered under a state action brought under such a law.

When billing incident to, the provider does not have to be physically present in the patient's treatment room while these services are provided, but they must provide what? a. Direct supervision and be present in the office suite b. Documentation in the record for the non-physician provider to follow c. An order in the patient's medical record for all procedures d. A signature stamp for claim submission

a. Direct supervision and be present in the office suite Rationale: To qualify as "incident to," services must be part of a patient's normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The provider does not have to be physically present in the patient's treatment room while these services are provided, but they must provide direct supervision (i.e., the physician must be present in the office suite to render assistance, if necessary).

The compliance officer for ABC Hospital explains to the physicians on staff that when the same service is billed to Medicare and then billed to a private insurance company or to the patient, this is referred to as what? a. Double billing b. Waste c. Clustering d. Abuse

a. Double billing

During an internal investigation, what is the next step after the regulatory scope and applicability are researched? a. Draft an audit protocol b. Hire an attorney c. Hire a consultant d. Start pulling records for review

a. Draft an audit protocol Rationale: After the regulatory scope and applicability are researched, an audit protocol should be drafted. The protocol should be carefully worded and tied back to the research. There should be an expectation that the government or opposing party is going to obtain a copy at some point in the negotiation. If an attorney does not draft the protocol, an attorney should review it for language.

Steve, at Orange Laboratories, wants to make sure that the lab stays in compliance with OIG guidelines. Which of the following is required for Steve to verify compliance? a. Ensure that there is a completed ABN. b. Make up information for claim submission purposes. c. Use computer programs that automatically insert diagnosis codes without receipt of diagnostic information from the ordering physician or other authorized individual. d. Create diagnosis information that has triggered reimbursement in the past.

a. Ensure that there is a completed ABN.

What does a search warrant, state or federal (or both), allow the agents the right to do? a. Enter and seize documents. b. Enter and photograph documents. c. Nothing; search warrants do not pertain to PHI. d. Enter and review documents.

a. Enter and seize documents.

The Department of Labor requires compliance with employee and employer laws including: a. FLSA, OSHA, CRA, and ERISA b. ADA, OCR, HHS, and HIPAA c. HIPAA, OCR, CRA, and FLSA d. OSHA, ADA, HIPAA, and ERISA

a. FLSA, OSHA, CRA, and ERISA The Department of Labor (DOL) requires compliance with employee and employer laws including the Fair Labor Standards Act (FLSA), the Occupational Safety and Health Act (OSHA), the Civil Rights Act (CRA), and the employment provisions of the Employee Retirement and Income Security Act (ERISA).

The CMP fine amounts are increased annually based on what act? a. Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015 b. Medicare Modernization Act of 2003 c. Health Insurance Portability and Accountability Act of 1996 d. Deficit Reduction Act of 2005

a. Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015

A medical billing company should have open and frequent communication regarding the mandatory responsibility to refund overpayments, and have this process documented, with whom? a. Healthcare providers b. Local government c. Clearinghouses d. Federal government

a. Healthcare providers

The purpose of EMTALA is to prevent which of the following? a. Hospitals from rejecting patients in a discriminatory manner by refusing treatment or transferring patients to "charity hospitals" or "county hospitals," because they are unable to pay b. Hospitals from admitting patients unable to pay and then transferring them to "charity hospitals" or "county hospitals" c. A hospital from incurring a large debt when a patient cannot afford to pay d. On-call physicians from not showing up when there is an emergency

a. Hospitals from rejecting patients in a discriminatory manner by refusing treatment or transferring patients to "charity hospitals" or "county hospitals," because they are unable to pay

The OIG acknowledges that full implementation of the OIG compliance program guidance may not be possible for small physician groups. When implementing a compliance program, which of the following are options for a provider's office? I. Focus on areas identified as risk factors during the monitoring and auditing process. II. Use the compliance plan for another entity as a starting point. III. Copy the OIG Compliance Program Guidance for Individual and Small Group Physician Practices and consider it the compliance program for the office. IV. Implement only the portions of the compliance program guidance that the providers agree to. a. I and II only b. I - IV c. III and IV only d. II and III only

a. I and II only Rationale: The OIG acknowledges that full implementation of all components may not be feasible for all physician practices and states a step-by-step approach can be used. Some physician practices may never fully implement all the components. As a first step, physician practices can adopt those components which, based on a practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit. Initially, compliance programs should focus on areas identified as risk factors during the auditing and monitoring step. If a provider has an existing relationship with an outside entity, such as a billing office, the provider may use their policies and procedures as a starting point.

During an internal investigation, creating an audit report for negotiation is important. What should overpayments (as well as underpayments) be included as? a. Offsets b. Voluntary disclosure c. Supporting documentation d. Revenue

a. Offsets

The OIG's publication of five special fraud alerts addresses joint venture relationships. Which of the following is considered problematic by the OIG? a. Investors are chosen because they are in a position to make referrals. b. The joint venture includes a shell laboratory. c. Investors are required to divest their ownership interest if they cease to practice in the service area. d. All of the above.

a. Investors are chosen because they are in a position to make referrals.

There are many benefits of having an effective compliance program. Which, of the below, is one such benefit? a. It shows that the practice is making a good faith effort to be compliant. b. It provides a means to cover errors until they can be fixed. c. It allows employees to retaliate against their employer when they believe they have been treated unfairly. d. It provides a basis for the OIG to create a CIA if a problem is identified.

a. It shows that the practice is making a good faith effort to be compliant. Rationale: Compliance programs provide a further benefit by showing that the physician practice is making a good faith effort to submit claims appropriately.

Under EMTALA, is there a violation for a physician who fails to respond to an emergency situation when they are assigned as the on-call physician? a. May be in violation of EMTALA and may subject them and the hospital to a penalty b. May be in violation of EMTALA because they should be on the hospital campus at all times when on call c. Is not in violation of EMTALA because they are only on call d. Is not in violation of EMTALA because EMTALA only relates to hospitals

a. May be in violation of EMTALA and may subject them and the hospital to a penalty Rationale: Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when they are assigned as the on-call physician. A physician who is on call and fails or refuses to appear after being called by another physician may be subject to a penalty under the statute or may subject the hospital to a penalty under the statute.

Under MSP, the Medicare statute and regulations require all entities that bill Medicare for items or services rendered to Medicare beneficiaries determine what? a. Medicare is the primary payer for those items or services. b. Medicare considers the item or service covered according to a National Coverage Determination. c. Workers' compensation is the primary payer for those items or services. d. Medicaid is the primary payer for those items or services.

a. Medicare is the primary payer for those items or services

How will Medicare respond to claims for lab services performed in physician office laboratories when the laboratory's CLIA number is not included on the CMS-1500 claim form? a. Medicare will deny the claim if the claim includes labs that are not CLIA waived. b. Medicare adjudicates the claim as usual because the CLIA numbers are automated in the Medicare claims system. c. Medicare pays the labs at 50 percent when the CLIA number is not included on the CMS-1500 claim form. d. Medicare sends the CMS-1500 claim form to the CLIA office for adjudication.

a. Medicare will deny the claim if the claim includes labs that are not CLIA waived.

What category of testing labs must have systems in place to monitor equipment, ensure proper test performance and results, and monitor the overall quality of the lab's operation? a. Moderate and high complexity b. High complexity only c. Moderate complexity only d. Waived

a. Moderate and high complexity

Under which circumstance is moonlighting services by an intern or resident considered as physician services? a. Moonlighting services are performed outside of the facility where the intern or resident has the training program. b. Moonlighting services by interns or residents are never considered as physician services. c. Moonlighting services are performed in an emergency department. d. Moonlighting services by interns or residents are always considered as physician services.

a. Moonlighting services are performed outside of the facility where the intern or resident has the training program.

When creating handicap parking spaces, which is true regarding four or less spaces? a. No handicap sign is required as long as there is an access aisle. b. One out of every five spaces must be van accessible. c. ADA must come and inspect the parking lot first. d. The handicap sign is required to be 6 inches wide by 14 inches high

a. No handicap sign is required as long as there is an access aisle.

What foreign languages does OSHA mandate the OSHA poster be posted in at each medical facility? a. No requirement b. Russian c. Spanish d. French

a. No requirement

If a facility is 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.

a. No, a CLIA number is not required if the facility only collects specimens and performs no testing.

Larry, compliance officer for Orange County Family Medical Group, is asked by one of the providers if it is alright to tell sexual jokes with the staff if they do not object. How should Larry reply? a. No. The provider is someone of authority and this is not acceptable. b. No, unless it is about the same sex that he is. c. Yes, as long as they are all over 21. d. Yes, as long as they do not object.

a. No. The provider is someone of authority and this is not acceptable.

Generally, routine screening procedures done as part of an asymptomatic annual examination for a Medicare patient are considered what? a. Non-covered services b. Allowable services c. Incident to d. Out of network

a. Non-covered services

As the new compliance officer for XYZ Billing Company, when should Tim start a compliance program for the third-party healthcare company? a. Now, to be proactive. b. Within the next few years because it's always best to be reactive with compliance. c. Within the next few years because it is not a requirement. d. Tim should wait and determine how many fraud violations occur within the next year before creating a compliance program.

a. Now, to be proactive.

Which office is responsible for enforcing the HIPAA Privacy Rule and Security Rule provisions? a. Office of Civil Rights (OCR) b. Department of Justice (DOJ) c. Department of Labor (DOL) d. Office of Inspector General (OIG)

a. Office of Civil Rights (OCR) Rationale: The OCR is responsible for enforcing the HIPAA Privacy Rule and Security Rule provisions.

The compliance officer for Orange County Family Medicine Group, explained to the front office staff how CLIA divisions are administered. Which one of the following is TRUE? a. States have CLIA divisions administered by the state. b. Regions have CLIA divisions administered by the Medicare office. c. Regions have CLIA divisions administered by the Recovery Audit Contractor. d. States have CLIA divisions administered by the Medicare Administrative Contractor.

a. States have CLIA divisions administered by the state.

Who should the Compliance Officer report directly to? a. The CEO, the managing physicians, and/or board. b. The CFO. c. CMS. d. The OIG.

a. The CEO, the managing physicians, and/or board.

What are the circumstances that allow modifier 25 to be used for additional payment for E/M services performed by a provider on the same day as a procedure? a. The E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. b. The E/M services are on the same day, and above and beyond the usual preoperative and postoperative care associated with the procedure. c. The E/M services are minimal, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. d. The E/M services are significant, related to the last visit, and above and beyond the usual preoperative and postoperative care associated with the procedure.

a. The E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. Rationale: Modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service is used to allow additional payment for E/M services performed by a provider on the same day as a procedure, as long as the E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. Different diagnoses are not required. This modifier must not be used to report an E/M service that resulted in a decision for surgery.

Routine waiver of copays would be considered a violation of which law? a. The anti-kickback statute b. Stark law c. False Claims Act d. HIPAA

a. The anti-kickback statute

What are two required elements of an authorization needed to disclose PHI? a. The authorization should have a right to revoke and an expiration date b. The authorization should have a spouse's signature and an expiration c. The authorization should be signed by an attorney and a spouse's signature d. The authorization should have an expiration and be signed by an attorney

a. The authorization should have a right to revoke and an expiration date

If a patient in the emergency department asks to be transferred to another hospital, what is one condition that must be met so that EMTALA is NOT evoked? a. The consent of the receiving hospital must be obtained. b. They cannot be transferred. c. The patient must be admitted first. d. The receiving hospital must be less than 10 miles away.

a. The consent of the receiving hospital must be obtained.

Kim, the compliance officer for Family Practice, provides training for the providers on the False Claims Act. She indicates the maximum federal penalty amount per false claim violation is $11,000 per claim plus three times the amount claimed for damages. Dr. Y says he heard the amount has been increased and wants to know what the discrepancy in the amount is? How should Kim respond? a. The penalties are increased annually based on the Civil Penalties Inflation Adjustment Act. b. The information the provider heard is incorrect as this fine amount does not increase. c. The penalties are increased as needed to cover the CMS budget. d. The penalties are increased annually based on the Civil Monetary Penalties Act.

a. The penalties are increased annually based on the Civil Penalties Inflation Adjustment Act. The False Claims Act (31 U.S.C. §§ 3729-3733) prohibits anyone from "knowingly" submitting false or fraudulent claims for payment. The Federal Civil Penalties Inflation Adjustment Act of 1999 increased the penalty to $5,500-$11,000 plus three times the amount of damages. Annually, the Civil Monetary Penalties Inflation Adjustment increases this amount. Penalties for violation of this law are calculated through the CMP law.

Which of the following represents a violation of the Stark law? a. The referring physician, or an immediate member of the referring physician's family, has a financial relationship with the entity receiving the referral b. The referring physician's best friend from medical school owns the entity receiving the referral c. The referring physician's neighbor owns the entity receiving the referral d. The referring physician's chiropractor owns the entity receiving the referral

a. The referring physician, or an immediate member of the referring physician's family, has a financial relationship with the entity receiving the referral Rationale: Stark law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. Specifically, if a physician (or immediate family member) has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services (DHS) for which the Medicare or Medicaid program would otherwise pay.

What is one of the responsibilities CMS has under the Medicaid Integrity Program? a. To hire contractors to audit Medicaid provider claims b. To educate providers on Medicaid and Medicare programs c. To hire contractors to audit Medicaid and Medicare provider claims d. To assist any state on combating Medicare fraud

a. To hire contractors to audit Medicaid provider claims

In relation to CIAs, what is the role of the IRO independent monitor? a. To specify the details of the IRO and the provider responsibilities toward the IRO b. To review all of the specifications of the CIA from the provider's standpoint. c. To review all communication between the IRO and the providers d. To specify all requirements of the provider to comply with the CIA

a. To specify the details of the IRO and the provider responsibilities toward the IRO

If an employee is injured at work with a "sharp" device that might be contaminated with another person's blood, what is the minimum information needed from the injured person? a. Type and brand of device involved in the incident; location of incident; description of incident. b. No information is needed. The person is just to get immediate treatment and follow rules, so the incident does not happen again. c. Name of supervisor so that a written warning can be issued to protect the employer. d. Name of the patient; medical record of the patient; recent labs of the patient.

a. Type and brand of device involved in the incident; location of incident; description of incident.

Kim, the compliance officer for ABC Medical Group, is reviewing claims submitted as Incident-to under the providers' NPIs. What must Kim keep in mind regarding group practices when reviewing the Incident-to claims? a. When the services are performed in a group practice, any physician member of the group may be present in the office to supervise. b. A nurse practitioner can report services incident-to a provider's service, regardless of supervision, if the state regulations allow it. c. Incident-to services may be performed in any setting. d. A nurse practitioner can report services incident-to a provider's service for both new patients and established patients.

a. When the services are performed in a group practice, any physician member of the group may be present in the office to supervise.

Stark law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. An example of this is if a physician has and which of the following have a financial relationship with an entity? a. Wife b. Cousin c. Friend d. All of the above

a. Wife This applies to immediate family members. The Stark law bans certain financial arrangements between a referring physician and an entity that bills the Medicare or Medicaid programs. Specifically, if a physician (or immediate family member) has a financial relationship with an entity, the physician is prohibited from making a referral to the entity for designated health services (DHS) for which the Medicare or Medicaid programs would otherwise pay.

Larry, the compliance officer for Orange County Family Medical Group, explains to the workers if non-specialty safety toe protective footwear is allowed to be worn off the job, Orange County Medical Group will what? a. Will not pay for the footwear b. Will pay for the footwear c. Will pay for part of the footwear d. Will not pay for the footwear, but will replace the laces for free

a. Will not pay for the footwear

What is one of the main responsibilities of the CMS regional offices? a. Work on quality initiatives b. Work on sanctioning providers from CMS c. Handling provider complaints about CMS d. Educating providers

a. Work on quality initiatives

If an employer does not meet requirements for FMLA, do they still a need leave of absence policy? a. Yes, they should still address leaves of absence requests. b. No, since they do not meet the FMLA requirements. c. Yes, if their state requires it. d. No, FMLA covers all leave of absence policies.

a. Yes, they should still address leaves of absence requests.

If a violation has occurred, Kim, Compliance Officer at ABC Provider Group, will be required to develop and/or coordinate what type of plan? a. corrective action b. self-disclosure c. correspondence d. refund

a. corrective action Rationale: If a violation has occurred, the Compliance Officer will be required to develop and coordinate a corrective action plan. This plan should include a description of the discrepancy; a description of the specific remedy that has been instituted, including any refunds of overpayment(s) that have been made; any disciplinary actions that have resulted from the violation; and a copy of any reports generated to any applicable government or third party payer.

It is important to educate employees regarding the methods they may utilize to directly notify and communicate issues of suspected areas of non-compliance. What is considered a best practice method of anonymous reporting? a. intra-office or USPS mail b. inter-office telephone call c. email d. a drop box near the ATM

a. intra-office or USPS mail Rationale: All parties should be informed of the methods they may utilize to directly notify and communicate with the Compliance Officer/Committee to report, discuss or receive clarification about policies and issues of suspected areas of non-compliance. Methods of reporting (including anonymous reporting) should be made readily available. In guidance for larger providers, the OIG has recommended a designated "hotline" to report compliance issues. Best practices for anonymous reporting are internal or external mail, and drop boxes in an area where privacy can be maintained. The OIG recommends an "open door" policy between the physicians and compliance personnel and practice employees.

For potential criminal violations, a practice should have immediate discussions with a criminal attorney who is what? a. is well versed in Healthcare Fraud and Abuse law b. is an experienced litigator c. is a certified coder d. handles medical malpractice cases

a. is well versed in Healthcare Fraud and Abuse law

Advance Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131. This section provides instructions regarding the notice issued by providers to beneficiaries in advance of providing what they believe to be ________ services. a. non-covered b. medically necessary c. deductible d. covered

a. non-covered

The final CLIA regulations were published on February 28, 1992 and are based on the complexity of the test method; thus, the more complicated the test, the more stringent the requirements. What are the three categories of tests that have been established? a. waived, moderate provider-performed microscopy (PPM), and high complexity b. low, medium, and high complexity c. low, moderate provider-performed microscopy (PPM), and high complexity d. waived, low provider-performed microscopy (PPM), and high complexity

a. waived, moderate provider-performed microscopy (PPM), and high complexity

Exclusion can result from violating any section of the Civil Monetary Penalties Law or from an individual or entity submitting a claim for reimbursement to a federal healthcare program for items or services furnished by an excluded person or entity. Penalties can be up to how much (prior to inflation)? a. $5,000 per claim, plus treble damages for the amount claimed for each item or service b. $11,000 per claim, plus treble damages for the amount claimed for each item or service c. $18,000 per claim, plus treble damages for the amount claimed for each item or service d. $10,000 per claim, plus treble damages for the amount claimed for each item or service

b. $11,000 per claim, plus treble damages for the amount claimed for each item or service

The BBA of 1997 created an alternate sanction allowing the government to levy a civil fine of up to how much for each violation of the anti-kickback statute? a. $20,000, and an assessment of three times the amount of the kickback b. $50,000, and an assessment of three times the amount of the kickback c. $75,000, and an assessment of three times the amount of the kickback d. $100,000, and an assessment of three times the amount of the kickback

b. $50,000, and an assessment of three times the amount of the kickback

What year was the Civil Rights Act implemented? a. 1967 b. 1964 c. 1969 d. 1965

b. 1964

When did the Needle Stick Safety and Prevention Act become effective? a. 2003 b. 2001 c. 2002 d. 2000

b. 2001

What percentage of compliance hotline calls pertain to human resource issues? a. 55 percent b. 50 percent c. 40 percent d. 25 percent

b. 50 percent

What safeguards cover maintenance of security measures to protect ePHI, and to manage the conduct of the covered entity's workforce in relation to the protection of ePHI? a. Technical safeguards b. Administrative safeguards c. Physical safeguards d. Facility safeguards

b. Administrative safeguards

When a provider believes that Medicare will not cover the service, what must the provider have signed by the patient prior to the service? a. Nothing when a signature is on file b. An ABN form c. A DME form d. A promise to pay form

b. An ABN form Rationale: Use of advance beneficiary notices (ABNs) — All providers and staff, including clinical laboratories, need to understand the proper use of ABNs. Important items include, but are not limited to: • Ensuring that the ABN is presented to the patient before the service is provided and providing an estimate of possible patient out-of-pocket expenses due to test not being covered by CMS • Using the most up-to-date CMS designated form • Never asking the beneficiary to sign a blank ABN • Used only when there is a genuine doubt regarding the likelihood of payment as evidenced by the reasons stated on the ABN

The compliance officer for Apple Hospital explains to the hospital board that a regulation governs relationships between competitors. What regulation is the compliance officer referring to? a. False Claims Act b. Antitrust law c. Anti-kickback statute d. Gainsharing

b. Antitrust law

ABC Medical office does not have professional coders on staff but has hired Amy to provide coding and billing compliance training for the staff. According to the OIG compliance guidance, when professional coding staff is not employed, who should be trained? a. All employees in the practice. b. Any individual directly involved with billing and coding. c. All managers in the practice. d. Only certified billers and coders should be trained.

b. Any individual directly involved with billing and coding.

The providers at ABC Family Medicine provide the codes for their services to the billing department. The compliance plan requires a review of the coding once a month. What is this an example of? a. Internal Review b. Monitoring c. A Work Plan d. Auditing

b. Monitoring

The cornerstone of the MACs' efforts to prevent improper payments is that each contractor's Error Rate Reduction Plan falls into three categories. Which item below is NOT one of the categories? a. Prepayment and post-payment claim review targeted to those services with the highest improper payments. In addition, in order to encourage providers to submit claims correctly, MACs can perform extrapolation reviews as needed. b. Assistance with developing new compliance plans for the providers that have failed audits in the past. c. Targeted provider education to items or services with the highest improper payments. d. New or revised local coverage determinations, articles, or coding instructions to assist providers in understanding how to correctly submit claims and under what circumstances the services will be considered reasonable and necessary.

b. Assistance with developing new compliance plans for the providers that have failed audits in the past.

Judy, the Compliance Officer for Apple Medical Group, wants the entire organization to be included in the initial audit to identify current compliance and areas of non-compliance. What is this type of audit? a. Desk b. Baseline c. Shadow d. Survey

b. Baseline

Which person can receive records of minors with custodial/non-custodial parents? a. The custodial parent only. b. Both parents have legal rights, unless ordered by judge otherwise. c. Both parents have legal rights, only if involved with joint custody. d. Neither parent; the court secures the records.

b. Both parents have legal rights, unless ordered by judge otherwise.

What department oversees the UPICs and MEDIC? a. Medicaid Fraud Units b. Center for Program Integrity c. Drug Integrity Contractor d. Recovery Audit Contractors

b. Center for Program Integrity

A physician practice is concerned with being flagged for audits. To avoid being flagged for an audit, the providers decide to report all office visits as a level 3. As the compliance officer for the practice, you inform the office manager that this is a compliance risk. What policy and procedure would you cite that could trigger an investigation or audit? a. Billing for items or services not performed b. Clustering c. Double billing d. Billing for medically unnecessary services

b. Clustering Rationale: Clustering, or coding/charging, one or two "middle" levels of service exclusively under the philosophy that some will be higher, some lower, and the charges will average out over an extended period. (This overcharges some patients while undercharging others.)

What is one way to discourage whistleblowers, mentioned in this chapter? a. Write policies and procedures b. Conduct performance reviews c. Perform background checks for office personnel d. Query the OIG and GSA databases for excluded individuals

b. Conduct performance reviews

Joan is the compliance officer for XYZ Community Hospital. To which workers does she give OSHA bloodborne pathogens training? a. All paid and non-paid workers at XYZ who might come into contact with bloodborne pathogens b. All healthcare workers at XYZ c. Only the nurses and physicians at XYZ d. All paid workers at XYZ who might come into contact with bloodborne pathogens

b. Container must be color-coded

Which one of the following is a requirement for a container used to store waste? a. Container cannot be located in stairwell b. Container must be color-coded c. Container cannot be in patient care areas d. Container must be red

b. Container must be color-coded

The Yates Memo of 2015 considers what factors? a. Physician wrongdoing b. Corporate wrongdoing c. International fraud d. Global fraud

b. Corporate wrongdoing

A physician who is on call and who fails or refuses to appear after being called by another physician to the emergency department is in violation of what? a. CLIA b. EMTALA c. JCAHO d. OSHA

b. EMTALA

When there is a government investigation including document reviews, what format of the files are typically requested? a. Paper b. Electronic c. Notarized d. Certified

b. Electronic

Which of the following helps in reducing exposure in the workplace by creating a barrier between an employee and a hazard that includes training in using medical devices in a safer manner? a. Policies and procedures b. Engineering controls c. Personal protective equipment d. Drills

b. Engineering controls

Which statement is TRUE regarding exit routes? a. There must be at least four exit routes per building. b. Exit routes are required to be free of objects allowing for unobstructed egress from the building. c. An exit door can be locked from the inside for a medical practice. d. An exit route can be temporary.

b. Exit routes are required to be free of objects allowing for unobstructed egress from the building.

What law(s) does not require that nursing facilities conduct state or Federal FBI Bureau of Investigation criminal background checks? a. False Claims law b. Federal law c. Federal and state laws d. State law

b. Federal law Rationale: Federal law does not require that nursing facilities conduct state or Federal Bureau of Investigation (FBI) criminal background checks. State laws may, however. It is important to confirm both sources for applicable laws.

What does the term RAT-STATS represent? a. Analysis of how many whistleblower cases have been filed b. Free statistical software used to select a random sample for audit c. Statistical analysis of how many patients return after therapy (RAT) in the nursing home setting d. Statistical software available from CMS to analyze claims data

b. Free statistical software used to select a random sample for audit Rationale: RAT-STATS is free statistical software that can be used to select a random sample for audit. The software is available on the OIG website.

Welfare benefit plans include which of the following? a. Retirement Plans b. Fringe Benefits c. Pension Benefits d. All of the above

b. Fringe Benefits

Welfare benefit plans include which of the following? a. Retirement plans b. Fringe benefits c. Pension benefits d. All of the above

b. Fringe benefits

Which state has mandated compliance for all providers that bill that states Medicaid? The state has a great website that details all of the 8 elements that it requires of its providers. a. California b. New York c. Washington, D.C. d. Texas

b. New York

OSHA requires that the employer report to OSHA all inpatient hospitalizations that are work related to OSHA within what time frame? a. 16 hours b. 12 hours c. Eight hours d. 24 hours

d. 24 hours

John is the compliance officer for ABC Family Medicine Group. The U.S. Assistant General's Office contacts him about an allegation pertaining to physician referrals. What will John need to do? a. Thank the U.S. Attorney General for the information and inform him that they will discuss this issue at the next board meeting. b. Gather the physician-related contracts for the group to give to their counsel for review. c. Pull some random charts to conduct an internal audit. d. Tell the U.S. Assistant General that the allegation is false, and he will need to call the attorney for the office that is out of town at the moment.

b. Gather the physician-related contracts for the group to give to their counsel for review.

Per this section, what can be an effective support system of the desired organizational culture? a. Auditing and monitoring b. HR policies and procedures c. Management d. Security personnel

b. HR policies and procedures

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established what comprehensive national program designed to combat fraud and abuse committed against all health plans, both public and private? a. National Plan & Provider Enumeration System (NPPES) b. Health Care Fraud and Abuse Control Program (HCFAC) c. Local Coverage Determinations (LCDs) d. Provider Enrollment, Chain, and Ownership System (PECOS)

b. Health Care Fraud and Abuse Control Program (HCFAC)

The Office of Inspector General works from within what organization to identify vulnerabilities in the healthcare system? a. Centers for Disease Control and Prevention b. Health and Human Services c. Office for Civil Rights d. Centers for Medicare and Medicaid Services

b. Health and Human Services

Which of these statements is TRUE? a. PBGC has a separate penalty from the other two agencies. b. IRS, DOL, and PBGC all have separate penalty assessments. c. DOL, DOJ, and DHHS all have same penalty assessments. d. IRS, DOL, and PBGC all have same penalty assessments.

b. IRS, DOL, and PBGC all have separate penalty assessments.

After an audit reveals areas for improvement, what is the next step a compliance officer should take? a. Call a staff meeting b. Implement corrective action plans c. Schedule an investigation only d. Notify the board

b. Implement corrective action plans Rationale: After an audit reveals areas for improvement, corrective action plans should be implemented.

What is the most important aspect of a compliance program? a. Training b. Implementation c. Development d. Discipline

b. Implementation Rationale: Without adherence to the stated goals and objectives, there is no purpose to the document itself. Having all the components of a compliance program in place will not matter if they are not implemented.

Kelly is the Compliance Officer for a teaching hospital. The hospital has providers that specialize in Dermatology, Pediatrics, Urology, Family Medicine, Internal Medicine and Infectious Disease. Only the Pediatricians accept Medicaid. The Family Practice group also employs Nurse Practitioners whereas the other specialties only have MDs and DOs. How should Kelly address these special issues? a. Kelly should have the organization decide on one way of running the practice. b. Kelly should give specialized training to the coders and billers that code and bill for the Pediatricians and Family Practice that takes into account the Medicaid insurance and Nurse Practitioners because it impacts those two out of the six specialties. c. Kelly should train all the coders and billers to know the billing rules for Medicaid and Nurse Practitioners for all the specialties. d. These are not issues at all. Compliance and training will not be affected.

b. Kelly should give specialized training to the coders and billers that code and bill for the Pediatricians and Family Practice that takes into account the Medicaid insurance and Nurse Practitioners because it impacts those two out of the six specialties. Rationale: Specialized compliance training is sometimes required. In some large provider groups, there are often different types of specialties. For example, within a multi-specialty practice, providers within the group may accept different insurance carriers from other providers within the group. The coding and billing staff at the office will need to understand how to bill for the different payers as well as how to bill for non-physician providers (NPP) if billing incident-to.

Which statement is TRUE regarding marketing providers who are credentialed with Medicare? a. A provider can market as approved by Medicare within a 100 mile radius of his practice. b. Marketing a provider as approved by Medicare is a violation of the Social Security Act. c. Marketing a provider as credentialed is only allowed once the provider has been contracted with Medicare for more than one year. d. A provider can market himself as credentialed or approved as the terms are used interchangeable.

b. Marketing a provider as approved by Medicare is a violation of the Social Security Act.

How long can an employee be off during an approved FMLA? a. Maximum 40 hours b. Maximum 12 weeks c. Maximum 200 hours d. Maximum eight weeks

b. Maximum 12 weeks

What department has a statewide investigative program of Medicaid fraud? a. Provider Fraud Unit b. Medicaid Fraud Control Units c. Office of Inspector General d. Centers for Medicare & Medicaid Services

b. Medicaid Fraud Control Units

What third party is in a unique position to discover fraud? a. Competing providers b. Medical billing companies c. Anyone who is involved in the medical industry d. Patients

b. Medical billing companies

Which of the following acts was signed into law and requires CMS to use competitive procedures to replace its current fraud inspections and carriers with a uniform type of administrative entity, referred to as Medicare administrative contractors (MAC)? a. Affordable Care Act (ACA) b. Medicare Modernization Act (MMA) c. Health Insurance Portability and Accountability Act (HIPAA) d. Health Information Technology for Economic and Clinical Health (HITECH)

b. Medicare Modernization Act (MMA) The cornerstone of the MACs' efforts to prevent improper payments is each contractor's Error Rate Reduction Plan (ERRP), which includes initiatives to help providers comply with the rules.

Which Medicare services require physicians to complete a Certificate of Medical Necessity (CMN)? a. Medicare-covered outpatient services (OPS) b. Medicare-covered durable medical equipment (DME) c. Medicare-covered long term care (LTC) d. Medicare-covered home health services (HH)

b. Medicare-covered durable medical equipment (DME)

What term refers to the altering or destroying of records that could be used as evidence? a. White out b. Spoliation c. Rendering d. Shred

b. Spoliation

Dr. X hires a nurse without looking to see if she was on the OIG's exclusion List. The nurse was previously convicted of committing fraud and was excluded. Dr. X receives payments from Medicare for services rendered to Medicare beneficiaries. Is it ok for Dr. X to have this nurse on staff? a. Yes, as long as the nurse pays a CMP. b. No, Dr. X will receive a CMP for hiring an excluded individual. c. Yes, as long as the nurse only assists with Medicare patients. d. No, the nurse may not work for anyone who sees Medicare beneficiaries ever again.

b. No, Dr. X will receive a CMP for hiring an excluded individual. Rationale: The OIG imposes Civil Monetary Payments and program Exclusion against individuals and entities who submit false claims to Medicare and Medicaid. The word excluded means that the individual or entity cannot work with (excluded) from all programs that deals with state or federal dollars.

How long does the Privacy Rule state that a practice or covered entity needs to retain medical records? a. Five years b. Not stated c. Six years d. Seven years

b. Not stated Rationale: The Privacy Rule does not include medical record retention requirements and covered entities may destroy such records at the time permitted by state or other applicable law.

Sue works for ABC Family Physicians. The providers at this office ask her to research the department that helps to protect patients from unfair treatment or discrimination? What department or agency would that be? a. Employment Equality Agency b. Office for Civil Rights c. Department of Justice d. Office of Inspector General

b. Office for Civil Rights Rationale: Civil rights help to protect individuals from unfair treatment or discrimination because of race, color, national origin, disability, age, sex (gender), or religion.

Which office performs independent audits of HHS programs and/or HHS grantees and contractors to examine their performance? a. Immediate Office of Inspector General b. Office of Audit Services c. Office of Evaluations and Inspections d. Office of Management and Policy

b. Office of Audit Services

Which department of the OIG conducts audits resulting in reduced waste, abuse, and mismanagement? a. Office of Investigations b. Office of Audit Services c. Office of Evaluations & Inspections d. Office of Management & Policy

b. Office of Audit Services Rationale: The Office of Audit Services provides independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.

Who is responsible for administering and enforcing HIPAA's Privacy, Security, and Breach Notification Rules? a. Office of Attorney General b. Office of Civil Rights c. World Health Organization d. Office of Medicaid

b. Office of Civil Rights

Which is NOT an OIG department? a. Office of Investigations (OI) b. Office of Civil Rights c. Office Audit Services d. Office of Management and Policy

b. Office of Civil Rights Rationale: The OIG Consists of six departments: 1. Immediate OIG 2. Office of Audit Services 3. Office of Evaluation and Inspections 4. Office of Management and Policy 5. Office of Investigation (OI) 6. Office of Counsel to the Inspector General

To meet EMTALA guidelines, if the patient requests the transfer but the physician doesn't agree, that should be documented and the patient should sign a request for transfer form. The patient's written acknowledgement of their refusal to consent to a physician-recommended transfer should also be documented. A physician must attest, in writing, that the medical benefits expected at the receiving facility should what? a. Have a guaranteed survival rate b. Outweighs the risk of transfer c. Be less expensive d. Be more expensive

b. Outweighs the risk of transfer

Which one of the following is NOT part of an exit route requirement for a medical facility? a. Posting evacuation routes in exam rooms b. Posting evacuation routes on company website c. Non-smoking building sign d. Posting evacuation routes in hallways

b. Posting evacuation routes on company website

Which of the following is TRUE per CMS website? a. Providers under CERT audit are subjected to RAC audits. b. Providers billing fee-for-service are subjected to RAC audits. c. PAs billing with incident-to services are subject to RAC audits. d. Providers billing Medicare PPOs are subjected to RAC audits.

b. Providers billing fee-for-service are subjected to RAC audits.

Kim, the compliance officer at Apple Rural Health Center, explains to the director of operations that the containers used to store, or transport infectious material should be which of the following? a. White, so informational tags can be seen easily b. Red, which is the standard color c. Black, as a warning color d. Black, to hide what is inside

b. Red, which is the standard color

In a CIA, the signatory page includes the signatures of the provider representatives (counsel and the compliance officer and/or president). What additional signatures are included on the signatory page? a. U.S. Attorney General b. Representative from the OIG c. Representative from the FBI and DOJ d. Office of Civil Rights Director

b. Representative from the OIG

What type of contractor has the main task of performing and/or providing support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs? a. RAC b. SMRC c. CERT d. UPIC

b. SMRC

The OIG has developed a five-principle strategy to combat healthcare fraud, waste, and abuse. Which of these options is NOT included in these principles? a. Establish payment methodologies that are reasonable and responsive to changes in the marketplace. b. Scrutinize individuals and entities that are participating as providers and suppliers after their enrollment in healthcare programs. c. Assist healthcare providers and suppliers in adopting practices that promote compliance with program requirements, including quality and safety standards. d. Vigilantly monitor programs for evidence of fraud, waste, and abuse.

b. Scrutinize individuals and entities that are participating as providers and suppliers after their enrollment in healthcare programs. Enrollment — Scrutinize individuals and entities that want to participate as providers and suppliers prior to their enrollment in healthcare programs.

Joan is an employee at XYZ Family Practice. What steps should be followed when she finds out one of the employees has been excluded from government programs? a. Suspend the employee from providing services to government program patients. b. Suspend the employee, request documentation, and investigate the matter. c. Terminate the employee immediately and refund the government payer. d. Suspend the employee from providing services and remove their salary from the Medicare cost report.

b. Suspend the employee, request documentation, and investigate the matter. When you find out that someone is excluded from federal programs, consider the following steps: • At least temporarily remove them from providing services. Discuss whether that will include all services or just government program services with your legal counsel. • Any paperwork regarding the exclusion should be reviewed and the individual should only be returned to duty when there is documentation of government reinstatement. • An analysis should be 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 items or services are not ordered or prescribed, the excluded person's salary, benefits, or contract cost would be analyzed to determine if they affect payment under a Medicare or Medicaid cost report.

Which of the following is a documentation guideline that will help an organization avoid overpayment demands and potential False Claim Act violations in the event of an audit by a third-party payer? a. Evaluation and management audits should be conducted at least annually. b. The CPT® and diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. c. The office should have a comprehensive policy and procedure manual. d. Medical record documentation must be completed the same day of the service.

b. The CPT® and diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

To ensure that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting, it is important to have what on the claim? a. The correct date b. The correct place of service c. The correct CPT® codes d. The correct diagnosis

b. The correct place of service Rationale: Physicians are required to identify the POS on the health insurance claim forms that they submit to Medicare contractors. The correct POS code ensures that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting.

As the compliance officer, Kim needs to review and revise certain policies yearly or as laws change. The CEO thinks that the policies should be unique to the office and specifically address some HR issues that have occurred recently. When writing documents, it is recommended to keep what thought in mind? a. They could be on the front page of the newspaper someday. b. The government could review them someday. c. There will be a lawsuit. d. An employee will be a whistleblower.

b. The government could review them someday.

Kim, the Compliance Officer for ABC Provider Group, created a compliance plan and policy one year ago. While reviewing the groups baseline audits, it comes to her attention that many of the staff have decided NOT to follow the compliance plan. Which statement is TRUE regarding this scenario? a. The non-compliance has created issues that will cause huge fines for the practice b. The non-compliance has created a big risk of the group and Kim needs to make sure that everyone knows about the risk of not following the compliance plan c. No issues of no-compliance have exist in the scenario. d. The non-compliance should be noted in the new plan and the group should try to be better about compliance the following year.

b. The non-compliance has created a big risk of the group and Kim needs to make sure that everyone knows about the risk of not following the compliance plan Rationale: Levels of non-compliance include (1) intentional or reckless disregard for policies and regulations (2) failure to detect violation (3) failure to report a violation. All employees, regardless of rank need to be held accountable for non-compliance.

According to Inspector General Daniel Levinson, what can help reduce enforcement on a provider from a corporate integrity agreement (CIA) to a certification of compliance agreement (CCA)? a. The provider demonstrates a compliance plan has been distributed to all employees. b. The provider has a robust and effective compliance program. c. The provider has compliance officer on staff. d. The provider keeps a copy of all coding rules which support their coding.

b. The provider has a robust and effective compliance program.

When is an outside consultant and/or legal counsel necessary? a. Only when an overpayment is identified. b. There is no requirement to hire a consultant or counsel, but such assistance may be beneficial during certain phases of development and/or if issues arise. c. In the beginning of plan development. d. Never.

b. There is no requirement to hire a consultant or counsel but such assistance may be beneficial during certain phases of development and/or if issues arise. Rationale: There is no requirement that outside consultants or legal counsel be involved in a compliance program. However, during certain phases of program development and implementation, both consultants and legal counsel may be beneficial.

What rights do patients have when paying for healthcare services with cash? a. They get a discount for not using a credit card. b. They can restrict the use of their PHI. c. They get a discount for not using a debit card. d. They may be paying less than their co-pay amount.

b. They can restrict the use of their PHI.

Kim, compliance officer for Apple Rural Health Center, explains to the staff that PHI can be used for which on of the following? a. Treatment, payment, and marketing b. Treatment, payment, or operations c. Treatment, procedures, and operations d. Treatment, procedures, and marketing

b. Treatment, payment, or operations

If an employee is injured at work with a "sharp" device that might be contaminated with another person's blood, what is the minimum information needed from the injured person? a. Name of the patient; medical record of the patient; recent labs of the patient. b. Type and brand of device involved in the incident; location of incident; description of incident. c. No information is needed. The person is just to get immediate treatment and follow rules, so the incident does not happen again. d. Name of supervisor so that a written warning can be issued to protect the employer.

b. Type and brand of device involved in the incident; location of incident; description of incident.

Who is charged with the responsibility to ensure safe and healthy working conditions? a. CMS b. CLIA c. OCR d. OSHA

d. OSHA

USSC is important as it related to the Federal Sentencing Guidelines and is thus related to the core elements of compliance. What does the USSC acronym stand for? a. United States Security Commission b. United States Sentencing Commission c. United States Sentencing Committee d. United States Security Committee

b. United States Sentencing Commission

Lab tests performed in the physician's office, such as urine dipsticks and finger-stick blood tests, are exempt from CLIA rules and are categorized as which one of the following? a. Easy tests b. Waived tests c. Simple tests d. Exempt tests

b. Waived tests

A board member of the ABC Internal Medicine Group asks John, the compliance officer, if they should be following the federal OSHA guidelines or the state guidelines. Currently the state guidelines are more stringent. What should John's reply be? a. We must follow the federal guidelines since these are federal rules. b. We must follow the most stringent, therefore the state, guidelines. c. We are allowed to choose as long as we meet the 90 percent rule and follow 90 percent of the rules. d. We must ask CMS for its recommendation and follow what they suggest.

b. We must follow the most stringent, therefore the state, guidelines.

When should an advance beneficiary notice (ABN) be presented? a. To every patient in case the service or procedure is not paid by Medicare. b. When an outpatient service is not a covered benefit/service of Medicare and the patient receives it before the service is provided. c. When a benefit/service is not covered by Medicare and the patient receives it after the service is provided. d. Never, as it may upset the patient.

b. When an outpatient service is not a covered benefit/service of Medicare and the patient receives it before the service is provided

In relation to reporting an incident, under what instances might the identity of the person reporting a compliance issue be disclosed? a. When other employees become involved. b. When governmental authorities become involved. c. When providers become involved. d. When board members become involved.

b. When governmental authorities become involved. Rationale: It should be made explicitly clear that although the organization will strive to protect an individual's identity, there may be instances where their identity must be disclosed if/when governmental authorities become involved. The Organization should have a written policy that explicitly states in what instances a person's confidentiality will not be maintained.Example: (Organization Name) will make every effort to protect an individual's identity, but in the event a regulating authority becomes involved in the investigation, an individual's identity may have to be disclosed.

Most expenses related to developing and implementing a compliance program are considered the cost of doing business and are tax deductible for the organization. Which of the following is NOT tax deductible? a. When the expense costs are more than the national average b. When the expenses are a result of the imposition of a penalty c. The annual maintenance of the program d. The salary of the compliance officer

b. When the expenses are a result of the imposition of a penalty Rationale: A CIA is a penalty imposed upon the organization and, as with any other governmental penalty, the expense of the development, implementation, and maintenance of this program cannot be included as a deductible expense to the organization.

Few cases go to trial. In today's courts there is tremendous pressure from the presiding judge to work out a settlement. When is litigation more likely to happen? a. When the provider has family members involved in the same case b. When whistleblowers are involved and there is potential for significant financial gain c. When it is the provider's first offence d. When the case involves commercial insurance carriers

b. When whistleblowers are involved and there is potential for significant financial gain

With regard to public disclosure, whistleblowers cannot bring claims based on information that has been disclosed in the following circumstances EXCEPT which of the following? a. In a congressional, administrative, or Government Accountability Office (GAO) report, hearing, audit, or investigation b. With personal knowledge of the claim c. News media d. In a criminal, civil, or administrative hearing

b. With personal knowledge of the claim

Texas Orthopedics submits false Medicare claims through its electronic data interchange to its Medicare Administrative Contractor (MAC) based in Oklahoma. Can the orthopedic office be charged with federal wire fraud? a. Yes because false claims were submitted. b. Yes because false claims were submitted electronically and across state lines. c. No because multiple provider groups must be involved for federal wire fraud to apply. d. No because federal wire fraud does not apply to Medicare claims.

b. Yes because false claims were submitted electronically and across state lines.

Jill is the compliance officer for Dr. X. Jill wants to send all lab referrals to the lab that her physician owns. Is this considered fraud? a. No, it is considered waste. b. Yes, it is considered fraud. c. No, it is considered abuse. d. Yes, only because lab services owned by providers is a special category so therefore it is fraud.

b. Yes, it is considered fraud. Rationale: Making prohibited referrals for certain designated health services is considered fraud.

Mrs. Smith does not like it that Dr. Jones states that she is obese in the medical record. She wants the word obese removed from her health record. Is this possible? a. No. The health record is a legal document. b. Yes. Mrs. Smith can request an amendment; however, it is up to Dr. Jones if he will grant it and make the change. c. No. Only incorrect information can be changed. d. Yes. Mrs. Smith can request such changes and Dr. Jones must comply within 60 days.

b. Yes. Mrs. Smith can request an amendment; however, it is up to Dr. Jones if he will grant it and make the change.

Modifiers provide a way for a physician to indicate a service or procedure that has been performed has been altered by some specific circumstance, but not changed in its definition or code. Assuming the modifier is used correctly and appropriately, this specificity provides the justification for payment for those services. In November 2005, the OIG published information that a modifier was being misused and provided guidance on the proper use of the modifier. In 2014, CMS released more specific modifiers to use for specific circumstances. What modifier was the report about? a. 81 b. 25 c. 59 d. 51

c. 59

A qui tam complaint is initially sealed for how many days? a. 30 b. They are never sealed c. 60 d. 90

c. 60

A clinical laboratory gets all of their Medicare patients to sign a blank ABN form in case Medicare does not pay for a service. This is part of their written policy. Is this a compliance risk? a. No; this is fine because it is a written policy of the clinical laboratory. b. Yes; a laboratory may never ask a patient to sign a blank ABN. c. Yes; the clinic should not have any patients sign an ABN. d. No; this policy will protect the laboratory from patients not wanting to pay their bill when Medicare does not pay.

b. Yes; a laboratory may never ask a patient to sign a blank ABN. Rationale: Use of advance beneficiary notices (ABNs) — All providers and staff, including clinical laboratories, need to understand the proper use of ABNs. Important items include, but are not limited to: • Ensuring that the ABN is presented to the patient before the service is provided and providing an estimate of possible patient out-of-pocket expenses due to test not being covered by CMS • Using the most up-to-date CMS designated form • Never asking the beneficiary to sign a blank ABN • Used only when there is a genuine doubt regarding the likelihood of payment as evidenced by the reasons stated on the ABN

Primary safety concerns in the medical setting include bloodborne pathogens, radiation, bio-hazardous waste, and what other concern? a. Closed spaces b. Chemicals c. Patient care equipment d. Non-patient care equipment

b. chemicals

MACs are responsible for administering the payment of Medicare services. Providers and suppliers submit their claims to the MAC and are paid based on __________. a. provider negotiations b. locally influenced fee schedules. c. national indicators d. AMA rules

b. locally influenced fee schedules.

What is a high-level statement or plan that embraces an organization's general beliefs, goals, objectives and acceptable procedure for a specified subject area? a. risk for the organization b. policy c. standard for all organizations d. compliance program

b. policy

When physicians (or their staff) make billing mistakes and errors that result in overpayment, what is the most important thing to do? a. apply a credit to the patient account b. send a refund c. document the error d. resubmit the claim

b. send a refund Correct Answer Reply:When physicians (or their staff) make billing mistakes and errors—which can happen given the number of regulations—simply refunding payments will often settle the account.

When Kim, the Compliance Officer for ABC Provider Group, is conducting a risk assessment. What is one of the most important and key sources of information Kim should utilize? a. journals b. the OIG Work Plan c. online email notifications d. newspaper articles

b. the OIG Work Plan Rationale: An initial step in auditing and monitoring is to determine what standards and procedures apply to the practice. Throughout the year, the OIG and Office of Medicaid Inspector General (OMIG) release work plans, which identify areas of risk they are and will be focusing on. It is important to know if any of their focus areas are applicable to your practice and warrant auditing and monitoring.

In a qui tam action in which the government intervenes, the relator is entitled to receive a monetary settlement between? a. 5-10 percent b. 10-20 percent c. 15- 25 percent d. 31-40 percent

c. 15- 25 percent

Under COBRA, the employer must permit qualified beneficiaries to elect to continue their health insurance under their current plan, depending on the qualifying event, for how long? a. 18, 26, 48 months b. 12, 16, 20 months c. 18, 29, 36 months d. 18, 20, 26 months

c. 18, 29, 36 months

President Franklin D. Roosevelt signed "Social Security" into law in what year? a. 1932 b. 1938 c. 1935 d. 1930

c. 1935

In what year did the OIG post guidance for hospitals? a. 1996 b. 1997 c. 1998 d. 1999

c. 1998 Rationale: The first set of OIG guidance for hospitals was created in 1998.

When did the Medicare Modernization act (MMA) become a law? a. 2008 b. 2000 c. 2003 d. 1996

c. 2003

In what year was the ADA amendment enacted? a. 2009 b. 2007 c. 2008 d. 2006

c. 2008

The typical duration of a corporate integrity agreement (CIA) is? a. 1-2 years b. Six months c. 3-5 years d. The agreement is permanent and does not expire

c. 3-5 years

Medicare requires physicians and mid-level providers to certify the need for physical, occupational, and speech therapy. The first certification is needed within how many days of starting therapy? a. 10 b. 20 c. 30 d. 60

c. 30 Rationale: Medicare requires that physicians and mid-level providers certify the need for physical, occupational, and speech therapy. The first certification is needed within 30 days of the patient starting therapy. After that, certifications are needed every 90 days. (Note: Some states may want recertification's every 30 days.)

How many states currently require nursing facilities to perform a background check of state records for direct-access employees? a. 10 b. 35 c. 43 d. 50

c. 43 Rationale: Out of 50 states, 43 have mandated background check requirements for individuals who have direct contact with SNF patient and/or their personal possessions.

How many days does a provider have to send a CERT contractor documentation? a. 60 days b. 30 days c. 45 days d. 90 days

c. 45 days

Payers expect all providers to refund monies that are overpayments. By law, how long does the provider have to refund overpayments once discovered? a. A timely manner, the specific number of days is not specified b. 60 days after receipt of overpayment c. 60 days after identification of overpayment d. 90 days after a request by the payer

c. 60 days of identification of overpayment Rationale: Under Section 6402 of the ACA, a provider must return an overpayment within 60 days of identifying the overpayment.

How many percutaneous injuries involving contaminated sharps occur annually? a. 400,000 b. 550,000 c. 600,000 d. 625,000

c. 600,000

What percent of OIG's resources are historically directed towards Medicare and Medicaid? a. 90% b. 60% c. 80% d. 75%

c. 80%

When is the recommended timeframe for a performance review? a. 30 days b. 60 days c. 90 days d. One week

c. 90 days

Which of the following is NOT required to be included in a bloodborne pathogen training program? a. A general explanation of the epidemiology and symptoms of bloodborne diseases b. An explanation of the basis for selection of personal protective equipment c. A printed list of questions and answers from the instructor d. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials

c. A printed list of questions and answers from the instructor

What should be readily accessible to all coding staff? a. Billing certification b. CPT™ code book c. All essential coding resources d. Nursing handbook

c. All essential coding resources Rationale: Coders must have up-to-date resources to code correctly and send out correct claims.

Which regulation was the Health Information Technology for Economic and Clinical Health Act (HITECH) enacted as part of? a. Health Insurance Portability Accountability Act b. Affordable Care Act c. American Recovery and Reinvestment Act d. Meaningful Use

c. American Recovery and Reinvestment Act

If a compliance problem is not detected, or is detected too slowly, the compliance program may require modification. What steps should the compliance officer take to determine what is necessary to prevent future violations? a. conduct training b. Immediate create new policies to add to the compliance program. c. Analyze the situation to determine if the compliance program failed to anticipate the detected problem. d. Start a full-fledged investigation to review the compliance of the entire practice

c. Analyze the situation to determine if the compliance program failed to anticipate the detected problem. Rationale: If a compliance problem is detected, the practice should analyze the situation to determine whether a flaw in the compliance program failed to anticipate the detected problem, or whether the compliance program's procedure failed to prevent the violation.

How often should the Tim, Compliance Officer for XYZ Community Hospital, update the Compliance Program/Compliance Plan? a. Twice per year b. When the providers determine it needs revision c. As laws and regulations change and at least annually d. Annually regardless of changes

c. As laws and regulations change and at least annually Rationale: Because of the changing nature of healthcare regulation, the compliance program will be a work in progress. The program should be monitored and updated at least annually, and likely more often, to provide for up-to-date compliance.

If a patient walks into your practice with a leashed dog, what should you do? a. Advise the patient that animals are not allowed inside the practice. b. Ask the patient if the dog is a service animal. c. Ask the patient if the dog is a service animal and, if the patient states yes, allow the animal on the premises. d. Ask the patient for the dog's ID tag indicating that it is a service animal.

c. Ask the patient if the dog is a service animal and, if the patient states yes, allow the animal on the premises.

The cornerstone of the MACs' efforts to prevent improper payments is that each contractor's Error Rate Reduction Plan falls into three categories. Which item below is NOT one of the categories? a. Targeted provider education to items or services with the highest improper payments. b. Prepayment and post-payment claim review targeted to those services with the highest improper payments. In addition, in order to encourage providers to submit claims correctly, MACs can perform extrapolation reviews as needed. c. Assistance with developing new compliance plans for the providers that have failed audits in the past. d. New or revised local coverage determinations, articles, or coding instructions to assist providers in understanding how to correctly submit claims and under what circumstances the services will be considered reasonable and necessary.

c. Assistance with developing new compliance plans for the providers that have failed audits in the past.

Billing companies should never code based on which of the following? a. Documentation provided by the provider b. The CPT® code set c. Assumption coding d. The diagnosis(es) code(s) provided by provider

c. Assumption coding Rationale: Additional areas that should be addressed in the billing company's policies and procedures as listed in the guidance includes assumption coding. This refers to the coding of a diagnosis or procedure without supporting clinical documentation. Coding personnel must be aware of the need for documented verification of services from the attending physician.

Kim of ABC Provider Group wants to put in a process that determines if the compliance program is effective. What is this often called? a. Enforcement b. Training c. Audit d. Policy

c. Audit

Why is the annual OIG Work Plan so important to compliance officers when they are developing their risk assessments? a. Because it shows the names of sanctioned providers b. Because the OIG mandates that compliance officers read the Work Plan c. Because it shows results of previous years' audit findings and the current year's focus d. Because the OIG Work Plan can help compliance officers develop workflows

c. Because it shows results of previous years' audit findings and the current year's focus

When a healthcare provider is alleged to have violated the law, OIG's first priority is to protect the U.S. Department of Health & Human Services' (HHS) programs and what else? a. Compliance office b. The healthcare staff c. Beneficiaries d. Substantial money

c. Beneficiaries

The bulk of the federal regulations in 42 CFR Part 4 cover the _________ ___________programs. a. Medicaid and SCHIP b. Medicare Part A and Medicare Part B c. Medicare and Medicaid d. Medicare and Tricare

c. Medicare and Medicaid

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

c. Certificate of registration

The Department of Labor (DOL) requires compliance with employee and employer laws. Which act is NOT overseen by the DOL? a. Fair Labor Standards Act (FLSA) b. Employee Retirement and Income Safety Act (ERISA) c. Clinical Laboratory Improvement Amendments (CLIA) d. Occupational Safety and Health Act (OSHA)

c. Clinical Laboratory Improvement Amendments (CLIA) Rationale: The Department of Labor requires compliance with employee and employer laws including, the Fair Labor Standards Act (FLSA), the Occupational Safety and Health Act (OSHA), the Civil Rights Act (CRA), and the employment provisions of the Employee Retirement and Income Safety Act (ERISA).

Every third-party healthcare company should designate someone to serve as the focal point for compliance activities. What is this position called? a. Compliance coordinator b. Physician c. Compliance officer d. Practice administrator

c. Compliance officer

What have OIG integrity agreements been a catalyst for change in? a. Fines b. Training c. Corporate culture d. Policies

c. Corporate culture

MICs can audit a Medicaid provider throughout their what? a. City b. County c. Country d. State

c. Country Rationale: An audit MIC can audit a Medicaid provider throughout the country.

Which PHI disclosures require tracking? a. All PHI disclosures b. Disclosures made for intelligence purposes c. Disclosures made to an attorney d. Disclosures made prior to the privacy standards date

c. Disclosures made to an attorney

Many times a compliance committee will review provider documentation on a regular basis. When a practice identifies that a provider is an outlier, it becomes most important to verify that the billed services are what? a. Scrubbed prior to submission b. Audited promptly c. Documented and coded accurately d. Submitted timely

c. Documented and coded accurately

During the new hire orientation, John (compliance officer) explained that EMTALA came about because some hospitals/physicians at the hospitals were doing what? a. Hurting patients b. Ignoring patients c. Dumping patients d. Disregarding patients

c. Dumping patients

The Medicare Modernization Act (MMA) of 2003 was implemented for which of the following to reduce medication errors due to physician's handwriting? a. Quality b. Electronic health record movement c. E-prescribing d. Whistleblower

c. E-prescribing

What is a requirement, for 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? 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

c. Enroll in the CLIA program

Which one of these employees does NOT fall under Category II under which there is a possibility of having to perform unplanned tasks that involve contact with blood or body fluids? a. Social workers b. Front office personnel c. Environmental services personnel d. Transportation department personnel (couriers, transporters)

c. Environmental services personnel

A compliance officer does not have to be a lawyer, but your chances of implementing a successful compliance program increases when you are familiar with which one of the following? a. Government programs b. Discipline policies c. Federal regulations d. Mathematics

c. Federal regulations

The compliance officer for Apple Hospital explains to the Board that, in general, the OIG recommends an audit of how many medical records per federal payer? a. 10 or more b. 12 or more c. Five or more d. Eight or more

c. Five or more In general, the OIG recommends auditing five or more medical records per federal payer or five to 10 random medical records per physician, or 10 percent of the payer's/physician's case volume.

Compliance certification agreements (CCAs) require providers to certify they will continue to operate their existing compliance program for a fixed term. What is the typical term of a corporate integrity agreement (CIA)? a. One year b. Three years c. Five years d. Seven years

c. Five years. Rationale: The typical term for a Corporate Integrity Agreement (CIA) is five years.

Kim, the compliance officer at Apple Rural Health Center, is asked by the HR manager: How long must she keep the information regarding employee OSHA exposures? What is Kim's reply? a. Until the corporation ceases to exist b. Until the employee resigns c. For 30 years past the time the employee resigns or is terminated d. Same as all health records, five years

c. For 30 years past the time the employee resigns or is terminated

The Compliance Program Guidance for Individual Physicians and Small Practices includes many components similar to previous guidance. Which of the following statements is unique to the OIG compliance program guidance for physicians? a. All components of the program guidance must be implemented, regardless of the hardship it places on a physician practice. b. Compliance plans are mandatory for provider offices. c. Full implementation of all components of the compliance program may not be feasible for a physician practice. d. Because provider's are required to follow facility compliance plans, it is not necessary for provider's to have compliance plans for the provider's office.

c. Full implementation of all components of the compliance program may not be feasible for a physician practice. Rationale: The OIG acknowledges that full implementation of all components may not be feasible for all physician practices and states a step-by-step approach can be used. Some physician practices may never fully implement all of the components. As a first step, physician practices can adopt those components which, based on a practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit.

The OIG is a division of which agency? a. CMS b. Medicaid c. HHS d. NGS

c. HHS

Hospitals with over 100 beds that violate EMTALA also may be subject to civil penalties and civil monetary penalties of up to how much? a. $20,000 per violation b. $30,000 per violation c. $10,000 per violation d. $50,000 per violation

d. $50,000 per violation

What does HITECH stand for? a. Health Information Team Educating Clinical Hospitals b. Health Information Technology for Education of Clinical Health c. Health Information Technology for Economic and Clinical Health d. Health Information Team for Educating Clinical Hospitals

c. Health Information Technology for Economic and Clinical Health

What is level three of the RAC claims appeals process? a. Redetermination by a MAC b. Reconsideration by a qualified improvement contractor (QIC) c. Hearing by an administrative law judge (ALJ) d. Review by the Medicare Appeals Council within the Departmental Appeals Board e. Judicial review in U.S. District Court

c. Hearing by an administrative law judge (ALJ) Rationale: Level three of claims appeals is a hearing by an Administrative Law Judge (ALJ)

Which of the following can be a result of an effective compliance program? a. Keep a provider from facing criminal penalties b. Make sure a practice or medical organization is 100 percent compliant with federal regulations c. Help create financial success, customer loyalty, community support, and employee satisfaction d. Require starting fresh with new policies and procedures and expensive changes

c. Help create financial success, customer loyalty, community support, and employee satisfaction Rationale: There is no guarantee that a compliance program will keep a provider from facing criminal penalties. However, it will help create a culture of compliance, which will lead to customer loyalty and increased employee satisfaction.

What goes hand in hand with compliance issues? a. Employee training b. Time off policies c. Human Resources d. Management

c. Human Resources

What agencies oversee ERISA? a. OIG, IRS, DOL b. DHHS, DOJ, PBGC c. IRS, PBGC, DOL d. DOL, DOJ, IRS

c. IRS, PBGC, DOL

Which of the following is a skilled nursing facility best practice guideline for the compliance officer? a. Only pull a report of your levels of therapy denied. b. Determine your lowest therapies billed. c. If audit determines claims did not meet medical necessity, report to CMS within 60 days. d. All of the above.

c. If audit determines claims did not meet medical necessity, report to CMS within 60 days.

When can patients instruct their provider not to share information about their treatment with their health plan? a. Never, patients must disclose all information to their health plan. b. Only if the patient tells the secretary when scheduling an appointment that their information should not be given to their health plan. c. If, when scheduling an appointment, the patient indicates that they are paying cash for the visit and do not want their information to be given to the health plan. d. Never, because the health plan has a contract with the provider.

c. If, when scheduling an appointment, the patient indicates that they are paying cash for the visit and do not want their information to be given to the health plan.

Dr. X is contracted with Medicare. After receiving the payment from Medicare, the difference between the total provider charges and the Medicare Part B allowable payment is billed to the Medicare beneficiaries. Which of the coding and billing risk areas identified in the OIG compliance guidance does this scenario implicate? a. Failure to properly use coding modifiers b. Billing for a non-covered service as if covered c. Inappropriate balance billing d. Submitting a claim for services that are not reasonable and necessary

c. Inappropriate balance billing Rationale: Inappropriate balance billing — The practice of billing Medicare beneficiaries for the difference between the total provider charges and the Medicare Part B allowable payment. Example: Medicare pays the full amount allowed for a service, such as an office visit, yet the provider still sends a bill to the patient for the office amount billed that Medicare did not cover.

What does the OIG consider the minimum requirement for a well-publicized guideline that includes disciplinary steps? a. Meeting with each employee to get a signature that they understand the guidelines. b. Consultants that come into the organization and do an in depth HR training. c. Including the disciplinary steps in the company's in-house training and procedure manuals. d. Frequent emails and information given on the Intranet.

c. Including the disciplinary steps in the company's in-house training and procedure manuals.

The 2018 Comprehensive Error Rate Testing (CERT) Report shows an 8.12 percent error rate among those providers billing Part B carriers/Medicare administrative contractors. What categories of errors comprise the top three highest error rates? a. Insufficient documentation, no documentation, and other b. Insufficient documentation, incorrect coding, and no documentation c. Insufficient documentation, medical necessity, and incorrect coding d. Medical necessity, incorrect coding, and no documentation

c. Insufficient documentation, medical necessity, and incorrect coding

What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)? a. Limited to investigating Medicaid HMO provider fraud b. Limited to investigating Medicare and Medicaid professionals c. Limited to investigating Medicaid provider fraud d. Limited to investigating mental health professionals

c. Limited to investigating Medicaid provider fraud

The Medicare program has program manual instructions on overpayments. Generally, overpayments are returned to the____________. a. NGS b. CMS c. MAC d. IRO

c. MAC

Joan is just learning about compliance and all of the various agencies that are involved in allegations and investigations. For a state fraud investigation, which agency is likely to get involved? a. RAC b. OCR c. MFCU d. MAC

c. MFCU Medicaid Fraud Control Units (MFCU) investigate and prosecute Medicaid fraud, as well as patient abuse and neglect in healthcare facilities.

Who investigates and prosecutes Medicaid fraud, as well as patient abuse and neglect in healthcare facilities? a. OIG b. RAC c. MFCU d. CMS

c. MFCU Medicaid Fraud Control Units (MFCU) investigate and prosecute Medicaid fraud, as well as patient abuse and neglect in healthcare facilities.

Third-party billing companies should have policies and procedures for addressing risk areas resulting from internal audits according to the OIG. Which risk area does this include? a. Tax status b. Employee turnover c. Marketing services d. Adherence to MGMA benchmarks

c. Marketing services Billing company incentives that violate the Anti-Kickback Statute or other similar federal or state statutes or regulations - For billing companies that provide marketing services, percentage arrangements may implicate the anti-kickback statute.

Under the federal guidelines, FMLA allows a person may take up to how many weeks off? a. 6 b. 4 c. 8 d. 12

d. 12

Mary, the compliance officer at Apple Community Hospital, explains to the CEO that the goals of the UPIC's data analysis program are to identify provider billing practices and services that pose the greatest financial risk to what program? a. CMS program b. Medicaid program c. Medicare program d. Medicare Advantage program

c. Medicare program

Which of the following is NOT a level of non-compliance? a. Failure to detect a violation b. Failure to report a violation c. Mistake in billing d. Intentional or reckless disregard for policies and regulations

c. Mistake in billing Rationale: The levels of non-compliance: 1. Intentional or reckless disregard for policies and regulations; 2. Failure to detect a violation; and 3. Failure to report a violation.

A Medicare-participating hospital that has specialized capabilities, such as a burn unit hospital, tells XYZ Hospital that they cannot take the burn patient because the Medicare patient population is costing them too much money. Are they allowed to turn away a burn patient if they have capacity and the patient is not yet on their property? a. Yes. The patient did not show up on their property. b. Yes. They have not admitted the patient yet. c. No. They are a Medicare participating hospital that specializes in burn patients so must take the patient. d. No. They must take all patients, even OB, if they participate in Medicare.

c. No. They are a Medicare participating hospital that specializes in burn patients so must take the patient.

What policy is written to encourage communication? a. Attendance policy b. Electronic protected information policy c. Non-retaliation policy d. Safety and security management policy

c. Non-retaliation policy Rationale: A non-retaliation policy for everyone, including employees and patients, is an important part of the compliance program to encourage communication, asking questions, obtaining clarification of policies and procedures outlined in the compliance program, and reporting of all incidents of potential misconduct.

If any employee is contacted by an outside agency regarding any issue within the organization, what is the first thing they should do? a. Call the other employees. b. Copy the requested records. c. Notify the compliance officer immediately. d. Help them get into the EHR.

c. Notify the compliance officer immediately.

What federal agency is in charge of employee safety? a. Department of Health and Human Services b. National Institute for Employee Health c. Occupational Safety and Health Administration d. Centers for Disease Control and Prevention

c. Occupational Safety and Health Administration

Which office would a compliance officer contact if they had a question regarding discrimination in certain healthcare programs? a. American Medical Association (AMA) b. Centers for Medicare & Medicaid Services (CMS) c. Office for Civil Rights (OCR) d. Office of Inspector General (OIG)

c. Office for Civil Rights (OCR)

Medicaid Fraud Control Units (MFCUs) operate under the direction of who? a. Center for Medicare & Medicaid Services (CMS) b. Department of Insurance c. Office of Inspector General (OIG) d. Recovery Audit Contractors (RAC)

c. Office of Inspector General (OIG)

A Medicare beneficiary does not like the appearance of the mole on her face. As a result, the provider removes the mole to improve the appearance. Should this be billed to Medicare? a. Yes, all services provided to Medicare beneficiaries should be billed to Medicare. b. Only if the patient cannot afford the service. c. Only if a denial is provided by Medicare and the bill is then sent to a secondary insurance carrier that will cover the service. d. No, services that are not medically necessary should never be billed to Medicare.

c. Only if a denial is provided by Medicare and the bill is then sent to a secondary insurance carrier that will cover the service. Rationale: The OIG's compliance guidance acknowledges that a physician should be able to order any tests, including screening tests, that he or she believes is appropriate for the treatment of a patient; however, a physician practice should be aware that Medicare will only pay for services that meet CMS' definition of "reasonable and necessary."

The RICO Act is a law that increases the severity of penalties for violations of what? a. HIPAA b. Human resources c. Organized crime d. Improper claim submissions

c. Organized crime

Providers must be enrolled in government programs to participate. They can do this either by paper versions or online through ____________. a. National Provider Identifier b. CMS's website c. PECOS d. HHS's website

c. PECOS

Joan, compliance officer for XYZ Community Hospital gives a new hire orientation. When training the new hire regarding information that can be given to people who call the hospital about the patient, what information is included? a. Patient name (when requesting individual knows patient's name), location in the facility, and the specific condition of the patient. b. Location in the facility, room number, and the specific condition of the patient. c. Patient name (when requesting individual knows patient's name), location in the facility, and a general one-word statement about the condition of the patient. d. Nothing can be said to the general public with a release of information statement.

c. Patient name (when requesting individual knows patient's name), location in the facility, and a general one-word statement about the condition of the patient.

The Apple Internal Medicine Group is having a board meeting. Tim, the compliance officer, explains that the most important concern for the Apple Internal Medicine Group's human resources department is which of the following? a. Compliance laws and the Americans with Disabilities Act b. OSHA and HIPAA c. Patient safety and information security d. FCA and OSHA

c. Patient safety and information security

Which regulation is violated when a physician is part owner of a hospital or imaging center and refers patients to that facility/center, unless specific OIG guidelines are followed? a. Corporate Integrity Agreement b. Anti-Kickback Statute c. Physician Self-Referral Act d. The Patient and Protection and Affordable Care Act

c. Physician Self-Referral Act

Once Hannah, Orange Hospital compliance officer, identifies the risk levels, what is the next step she should take? a. Prioritize which training courses should be scheduled. b. prioritize which policies will be updated. c. Prioritize which risks will be addressed. d. Determine if overpayments are due.

c. Prioritize which risks will be addressed.

What does the OIG Compliance Program Guidance acknowledge patient care as? a. Irrelevant to having an effective compliance program. They are not related. b. Important but should not get in the way of implementing all seven recommended elements. c. Providers should put patients first in a compliance program. d. The main reason offices fail to implement compliance programs in the first place.

c. Providers should put patients first in a compliance program. Rationale: Compliance officers (COs) should implement a "patients first" compliance model, and enlist buy-in from clinicians by demonstrating that compliance programs improve patient care.

What is the main purpose of the HIPAA Omnibus Rule? a. Provides employee with better education b. Provides providers with the ability to correct PHI c. Provides individuals new rights with regard to their health information d. Provides safeguards for attorneys when handling PHI

c. Provides individuals new rights with regard to their health information

The OIG believes physician practices can realize numerous benefits by implementing a compliance program. Which of the following is a stated benefit of a well-designed compliance program? a. Help providers eliminate risk of an audit. b. Avoid the need for medical coders. c. Reduce the chances of an audit. d. Improve the Medicare reporting requirements for the Quality Payment Program.

c. Reduce the chances of an audit. Rationale: Benefits of implementing a well-designed compliance program help to speed and optimize proper payment of claims, as well as: • Minimize billing mistakes and optimize proper payment of claims; • Help protect patient privacy; • Reduce the chances of an audit; and Avoid conflicts of interest and help comply with the self-referral and Anti-Kickback Statutes.

Employees should be told that if they are questioned in an investigation, they have the right to what? a. Refuse to cooperate and go home b. Pull patient records to refresh their memory c. Request an attorney d. Request a warrant

c. Request an attorney

Exposure determination is made by which one of the following? a. What personal protective equipment was used b. The location of the contact c. Reviewing job classifications d. Whether cat litter was used to clean spill

c. Reviewing job classifications Exposure determination shall be made without regard to use of personal protective equipment. It is made by reviewing job classifications within the work environmen

What should not be ignored and may require necessary policy measures to prevent avoidable recurrence? a. Compliance program b. Control measures c. Risk areas d. Work flow

c. Risk areas Rationale: Monitoring risk areas will indicate vulnerable areas for fraud and abuse that need addressing. Compliance officers can use the results to develop any necessary policies and procedures.

The aim of this program was to ensure that every child under the age of 18 had medical coverage. a. HHSP b. CHIPS c. SCHIP d. ACA

c. SCHIP

If a referred patient to your practice has hearing deficit and needs an appointment, what steps should your practice take when scheduling? a. Ask the patient to bring an interpreter with them to the visit. b. Kindly explain to the patient that they cannot be seen because the practice does not have the ability to communicate with the hearing impaired. c. Schedule the appointment a few days ahead and arrange for an interpreter. d. Schedule the appointment, advise the patient of the charge for the interpreter, and ask how they will pay for the services

c. Schedule the appointment a few days ahead to arrange for an interpreter.

Kim is the compliance officer for Apple Rural Health Center. She is explaining to the board of directors that all hospitals must follow the EMTALA laws with what exception? a. No exceptions b. Indian Health Services c. Shriners Hospital for Children, Indian Health Services, and Veterans Affairs hospitals d. Veteran Affairs

c. Shriners Hospital for Children, Indian Health Services, and Veterans Affairs hospitals

Under FMLA which situation is NOT allowed to be taken for military caregiver leave? a. A brother in the Reserves and whose right leg was just traumatically amputated in a recent deployment to Iraq b. Father who has medical conditions from a chemical that he was exposed to in his last deployment to the Middle East six months ago and was honorably discharged from the National Guard because he can no longer perform regular duties c. Spouse that has been seriously injured in a car accident that was dishonorably discharged from the armed forces a year ago d. Next-of-kin, such a first cousin, that was injured during active duty in the armed forces

c. Spouse that has been seriously injured in a car accident that was dishonorably discharged from the armed forces a year ago

Which one of the following is not a component of PHI? a. Patient's name b. Patient's address c. Spouse's name d. Patient's telephone number

c. Spouse's name

Physicians sometimes own other health-related businesses, such as physical therapy facilities, DME or home health companies, diagnostic imaging centers, or laboratories. Because these businesses provide designated health services, which regulation is triggered? a. False Claims Act b. Anti-kickback Statute c. Stark Law d. Qui Tam Provisions

c. Stark Law

Which law provides for a civil monetary penalty (up to $15,000 per service) and exclusion from government programs in any case where a person submits an improper claim, which was known to have been, or should have been known to have been, provided through a prohibited referral, and has not refunded the payment? a. Anti-kickback statute b. Health Insurance Portability and Accountability Act c. Stark law d. Qui tam provisions

c. Stark law

When a compliance program is established, what does the OIG recommend a billing company do regarding the company's operations? a. Audit the financials b. Complete a staff report on each employee c. Take a snapshot from a compliance perspective d. Demand corrective action

c. Take a snapshot from a compliance perspective

In an internal investigation, if your attorney does the interview, what is important for the employee to know? a. That the interview will be strictly confidential. b. That the attorney is also the employee's attorney. c. That the attorney is not the employee's attorney. d. That the interview protects the employee under attorney client privilege.

c. That the attorney is not the employee's attorney.

Penalties for mail fraud for persons who knowingly and willfully scheme to defraud a healthcare benefit program that results in serious bodily injury include fines and imprisonment of up to how many years? a. 12 b. 10 c. 25 d. 20

d. 20

Records associated with a compliance inquiry will include the nature of the inquiry or report, the investigation procedures and outcomes, and all actions taken by the Compliance Officer and the organization to rectify any non-compliance uncovered. Who should the Compliance Officer keep apprised of ongoing investigations and the results when managing incidents and investigations? a. CMS b. OIG c. The Board of Directors d. Staff

c. The Board of Directors Rationale: The organization will maintain a file of all records associated with an inquiry to the Compliance Officer and any reports of suspected noncompliance within the organization. Files will include the nature of the inquiry or report, the investigation procedures and outcomes, and all actions taken by the Compliance Officer and the organization to rectify any non-compliance uncovered. The owner(s), managing physician(s), or Board of Directors will be kept apprised of all ongoing investigations and the results of all closed investigations.

Tim is a patient at ABC Internal Medicine Group. Tim is HIV positive. ABC Internal Medicine Group is in a state which requires providers to report HIV cases. What does John, the compliance officer, explain to Tim regarding how ABC Internal Medicine Group will handle his PHI? a. All of Tim's information will be kept confidential. b. Tim's information will only be released if Tim has signed a release form. c. The information is released to the state based on regulation, but will otherwise not be released with an authorization form. d. Tim's information will be released when requested by anyone in his family.

c. The information is released to the state based on regulation, but will otherwise not be released with an authorization form.

Compliance Officer for ABC Medical Group has developed an auditing and monitoring policy and procedure to audit each provider annually, and increase the audits quarterly when a provider is below a 75% accuracy rate. The audits are performed annually. Provider A obtains 90% accuracy, Provider B obtains 80% accuracy, and Provider C obtains 70% accuracy. A corrective action plan is put in place and the Compliance Officer schedules the next audit for the next year. Other than the inaccurate coding, which of the following is considered a compliance risk for this scenario? a. A corrective action plan is put in place. b. The audits are scheduled by the compliance officer. c. The policy is not being followed. d. The policy does not allow for errors.

c. The policy is not being followed. Rationale: The OIG believes standards and procedures are important, and will look for them in the event of an investigation. The standards and procedures should be appropriate to the practice size. DO NOT put standards and procedures in place that will not or cannot be followed. Creating a higher standard than required by the laws and regulations is problematic because the government will try to hold the practice to that higher standard.

A Compliance Corrective Action (CCA) Plan might deal with which item below? a. A nurse steals medication samples. b. An employee alters their timecard. c. The provider does not complete documentation timely. d. The CEO takes too much time off from work.

c. The provider does not complete documentation timely. Rationale: If a compliance problem is detected, the practice should analyze the situation to determine whether a flaw in the compliance program failed to anticipate the detected problem, or whether the compliance program's procedure failed to prevent the violation. Timely note completion is just one of the many examples that might violate your State or CMS guidelines and require a corrective action plan.

The specific terms of a particular CIA depend on the facts and circumstances related to that case and that provider. What do CIAs almost always incorporate into the provisions? a. An Independent Review Organization b. Civil monetary payments or other fines c. The seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines d. Expert witness testimony that elaborates on why there is a CIA

c. The seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines

The providers at XYZ Community Hospital want to leave the computers turned on and have no passwords because it takes too many clicks to get into a password-protected computer. How should the compliance officer reply? a. This is a bad example to the rest of the employees and breaks HIPAA rules. b. This is a bad example for the nurses and breaks the HIPAA rules. c. This is against the hospital's HIPAA policy, as well as the HR policy that states that they will protect the information in the computer that the hospital allows them to use on the premise. d. This is a bad example for the patients and breaks HIPAA rules.

c. This is against the hospital's HIPAA policy, as well as the HR policy that states that they will protect the information in the computer that the hospital allows them to use on the premise.

Which is the underlying principle of the Equal Employment Opportunity law? a. This law requires all persons to be entitled to equal employment opportunity regardless of race, religion, or national origin. b. This law requires all minorities to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. c. This law requires all persons to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. d. This law requires all persons be entitled to equal employment opportunity regardless of sex, age, or disability.

c. This law requires all persons to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law.

How many years can RACs look back from a date of service? a. Six b. Two c. Three d. Four

c. Three

How many agencies oversee ERISA? a. One b. Two c. Three d. Four

c. Three Three agencies oversee ERISA: IRS, DOL, and PBGC.

Why must an employer implement an exposure control plan? a. To reduce their malpractice insurance premiums b. To ensure that the employer does not receive penalties for not doing so c. To ensure proper employee protection measures d. To make sure all employees are trained on HIPAA guidelines

c. To ensure proper employee protection measures

What is the mission of the Office of Inspector General (OIG)? a. To make sure that all providers who are doing fraudulent billing face criminal prosecution. b. To ensure that health care workers get the resources they need to be successful. c. To protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. d. To ensure that welfare is not being taken for granted and that only those persons who qualify under federal poverty guidelines are receiving government assistance.

c. To protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

Why is an ergonomics policy important? a. To stop employees from unnecessary pushing. b. To stop employees from forceful lifting c. To take preventative actions of musculoskeletal disorders d. To stop employees from stressing out on the job

c. To take preventative actions of musculoskeletal disorders

CLIA certificates are valid for how long? a. Seven years b. One year c. Two years d. Five years

c. Two years

What description below best describes UPICs? a. UPICs are federal companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments. b. UPICs are state companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments. c. UPICs are private companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments. d. UPICs are private companies contracted by the OIG, used to conduct audits for Medicare and Medicaid overpayments.

c. UPICs are private companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments. Rationale: UPICs are private companies. They do not work on contingency fees; therefore, they are paid directly by CMS. The primary goal of the UPIC is to identify cases of suspected fraud, develop them thoroughly, and take immediate action.

Which office is at the top level of concern and usually involved in whistleblower actions and national investigations? a. Office of Inspector General b. Health and Human Services c. United States Attorney's Office d. Office of Medicaid Inspector General

c. United States Attorney's Office

CLIA is funded by whom? a. Medicare Administrative Contractors (MACs) b. Patients c. Users d. The Centers for Medicare and Medicaid Services (CMS)

c. Users

How soon are practices or medical organizations required to process a patient's request for medical records when the information is maintained or accessible onsite? a. The timeframes are per state law. b. As soon as possible. c. Within 30 days. d. Within 60 days.

c. Within 30 days. The covered entity must act on the request within 30 days of its receipt if the information is maintained or accessible on-site, or within 60 days if it is not.

An emergency doctor at XYZ Community Hospital asks the compliance officer, Joan, if he is allowed to treat a patient that comes into the ER but is alone and has dementia. He needs to release the PHI to the pharmacy for medicine. How should Joan reply? a. No, next of kin needs to be located first. b. Yes, if the person normally goes to that hospital pharmacy. c. Yes, PHI can be disclosed to another person or entity if the individual is incapacitated or otherwise unable to agree or object to a disclosure due to emergency circumstances d. No, all PHI is protected, under any circumstance.

c. Yes, PHI can be disclosed to another person or entity if the individual is incapacitated or otherwise unable to agree or object to a disclosure due to emergency circumstances

Are there certain rules for PHI disclosure in cases of an emergency? a. No, especially if the patient is not able to provide consent. b. No, there is not a separation of emergency treatment. c. Yes, PHI can be released for emergency treatment. d. No, PHI cannot ever be disclosed without patient consent.

c. Yes, PHI can be released for emergency treatment.

If a person presents to the emergency department and collapses outside the ER doors, is EMTALA evoked? a. No, the emergency department is not considered "on the hospital campus." b. No, the patient must be inside the emergency room for EMTALA to apply. c. Yes, the 250-yard zone applies in this case. d. Yes, but only if they are in active labor.

c. Yes, the 250-yard zone applies in this case.

Kelly reported Dr. X to the Compliance Officer for inappropriately billing higher levels of E/M services than performed. Matthew, the supervisor at the same practice is providing bonuses for members of his staff. Because Kelly had cost the company money in auditing Dr. X, she was not given a bonus. Is this a compliance risk and why? a. No; the lack of a bonus is not sufficient enough to be considered a compliance risk. b. No; the supervisor made a valid decision in balancing the finances for the practice. c. Yes; this is considered retaliation for reporting compliance issues. d. Yes; this is considered a violation of HIPAA.

c. Yes; this is considered retaliation for reporting compliance issues.

The risk assessment is an essential component of the compliance officer's responsibilities. Once a compliance officer first reviews the relevant documents, what is the next step? a. start creating policies and procedures b. conduct a root cause analysis c. conduct audits based on the risk assessment findings d. conduct coding training

c. conduct audits based on the risk assessment findings Rationale: The Compliance Officer will review all of the relevant documents, perform and/or coordinate an organization audit, and review all areas of possible noncompliance within the organization. This assessment will indicate in what areas of the organization are currently in compliance and which areas are not.

The compliance program will flounder if employees of the organization are not aware of what? a. applicable laws and regulations that pertain to the board of directors. b. applicable laws and regulations that pertain to provider documentation requirements. c. laws and regulations that pertain to their specific job descriptions. d. laws and regulations that pertain to the compliance officers job descriptions.

c. laws and regulations that pertain to their specific job descriptions.

Kim is the Compliance Officer for ABC Provider Group. Kim has read the OIG Compliance Program Guidance that acknowledges patient care as the first priority of a physician practice. As the Compliance Officer, Kim should implement a compliance model that puts what first? a. safety b. privacy c. patients d. quality

c. patients Rationale: The OIG Compliance Program Guidance acknowledges patient care as the first priority of a physician practice. Compliance Officers (COs) should implement a "patients first" compliance model, and enlist buy-in from clinicians by demonstrating that compliance programs improve patient care. For example, thorough medical records documentation will result in fewer medical errors, thereby enhancing patient outcomes.

The OIG's ______ sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. a. contractors b. inspectors c. work plan d. goals

c. work plan

Why did OSHA publish a bloodborne pathogens standard? a. Because of significant exposure to asbestos b. Because of significant health risks c.Because of significant exposures to viruses and other microorganisms d. Because of significant exposure to airborne pathogens

c.Because of significant exposures to viruses and other microorganisms

The Medicare Learning Network (MLN) began in _________. a. 2000 b. 2005 c. 2002 d. 2004

d. 2004

What are designated health services? a. Clinical laboratory services b. Physical therapy services c. Home health services d. All of the above

d. All of the above Designated health services include:• Clinical laboratory services • Physical therapy services • Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services • Radiation therapy services including supplies• Parenteral and enteral nutrients, equipment, and supplies • Prosthetics, orthotics, and prosthetic devices and supplies• Home health services • Outpatient prescription drugs • Inpatient and outpatient hospital services

Where can a compliance officer from a family practice look for information on risks specifically associated with their practice type? a. American College of Cardiology b. American College of Physicians c. American Academy of Dermatology d. American Academy of Family Physicians

d. American Academy of Family Physicians

ABC medical group has implemented a new compliance program. According to the OIG, how often should ongoing audits be performed? a. Monthly b. Every 6 months c. Bi-annually d. Annually

d. Annually

In certain cases, a provider, practitioner, or supplier who accepts "insurance only" and routinely waives Medicare copayments or deductibles also could be held liable under what law? a. Qui tam provisions b. Stark law c. False Claims Act d. Anti-kickback statute

d. Anti-kickback statute

What regulations may some joint ventures violate? a. Enrollment process. b. Claims processing manual c. False Claims Act d. Anti-kickback statute

d. Anti-kickback statute

When patients are referred to home health agencies and/or DME suppliers, what is identified as an area of concern? a. Joint ventures b. HIPAA c. DRG creep d. Anti-kickback statute

d. Anti-kickback statute

If a group pays a hospital monthly rent for office space that is one-half the going rate or fair market value, this is a violation of which regulation? a. Stark law b. FCA c. CMS guidelines d. Anti-kickback statute

d. Anti-kickback statute Examples of anti-kickback statute violations: • A hospital providing rental rates below fair market value to a physician who refers business to the hospital • Routine waiver of copayments or deductibles for patients under Medicare Part B • A drug or equipment supplier providing free benefits to a provider who utilizes their product • A physician who is paid exorbitantly for speaking engagements by a company to whom the provider refers business

The OIG and the American Health Lawyers Association (AHLA) have co-sponsored documents in an effort to assist the directors of healthcare organizations. The most recent document to assist Board of Directors was collaborated on with the OIG, AHLA, HCCA, HHS and: a. Association of Hospital Administrators (AHA) b. Association of Certified Fraud Examiners (ACFE) c. Association of CPA Healthcare Auditors (ACPAHA) d. Association of Healthcare Internal Auditors (AHIA)

d. Association of Healthcare Internal Auditors (AHIA) Response Feedback: In April 2015, the OIG along with the Association of Healthcare Internal Auditors (AHIA), the American Health Lawyers Association (AHLA), the Health Care Compliance Association (HCCA), and the U. S. Department of Health and Human Services (HHS) formed a taskforce and released the Practical Guidance for Health Care Governing Boards on Compliance Oversight.

A standard boiler plate clause in a CIA includes language on the rights of the OIG to inspect any aspect of the provider's business under what circumstances? a. Under supervision of an attorney b. With a search warrant c. With 30 days' notice d. At any time

d. At any time

RACs perform what type of review(s)? a. Automated b. Prospective c. Complex d. Automated and complex

d. Automated and complex Rationale: There are two types of reviews: automated (no medical record needed) and complex (medical record required).

Under what circumstances can a relator not file or pursue a qui tam action? a. If they are a new employee b. The qui tam action is based upon information that has been disclosed to the public c. The government already is a party to a civil or administrative money proceeding d. Both b and c

d. Both b and c The FCA provides several circumstances when a relator cannot file or pursue a qui tam action: 1 - The relator was convicted of criminal conduct arising from their role in the FCA violation 2 - Another qui tam concerning the same conduct already has been filed (this is known as the "first to file bar") 3 - The government already is a party to a civil or administrative money proceeding concerning the same conduct 4 - The qui tam action is based upon information that has been disclosed to the public through any of several means: criminal, civil, or administrative hearings in which the government is a party, government hearings, audits, reports, or investigations, or through the news media (this is known as the "public disclosure bar"). There is an exception to the public disclosure bar where the relator was the original source of the information.

Which President signed into law the FMLA Leave Entitlements for Military Families? a. Obama b. Clinton c. Carter d. Bush

d. Bush

Which one of the following monitors the MACs? a. OIG b. UPICs c. RACs d. CERT

d. CERT

The billing manager for a physician practice sometimes uses the term "double billing." What does this phrase refer to? a. Billing for the spouse of the patient, as well as for the patient. b. Collecting the patient co-pay twice every time the patient comes in to see the provider. c. Billing the office visit twice every time the patient comes in to see the provider. d. Charging the patient for a membership fee to see the provider as well as billing for the actual office visit that day.

d. Charging the patient for a membership fee to see the provider as well as billing for the actual office visit that day. Rationale: Double billing results in duplicate payment. For example, charging a Medicare patient a fee just to be a member of your practice, and then also charging Medicare the fee for the services rendered to the patient (i.e. office visit).

Which statement is TRUE regarding compliance programs? a. Compliance programs are not mandated by law. b. Compliance programs are only effective after the baseline audit has been performed and policies written. c. Compliance programs are only required by law for healthcare entities that have more than $500,000 in annual revenue. d. Compliance programs are considered more dangerous if they are developed but not implemented.

d. Compliance programs are considered more dangerous if they are developed but not implemented. Rationale: The only thing worse than not having a compliance program, is to have a compliance program that is not implemented.

For providers demonstrating trustworthiness, the OIG waives its exclusion authority concurrent with resolution of monetary liability under the False Claims Act and the CMP Law. What do these settlements typically include? a. Qui tam b. Advisory opinion c. Realtor d. Corporate integrity agreement

d. Corporate integrity agreement

Which government department is comprised 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. Health Care Lawyers Association d. Department of Justice

d. Department of Justice Rationale: The Department of Justice (DOJ) works closely with the OIG. It is comprised of more than 105,000 employees, including hundreds of lawyers who enforce the nation's federal criminal laws and help to develop and implement criminal law policies. Their role in healthcare fraud and healthcare compliance is to investigate and prosecute healthcare crimes.

Which federal government departments is the OIG NOT responsible for overseeing? a. Centers for Medicare & Medicaid Services b. Centers for Disease Control and Prevention c. U.S. Food & Drug Administration d. Drug Enforcement Agency

d. Drug Enforcement Agency Rationale: The OIG is responsible for overseeing the Centers for Medicare & Medicaid Services (CMS), and programs under other HHS agencies, including the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the U.S. Food and Drug Administration (FDA). The Drug Enforcement Agency (DEA) is overseen by DOJ.

The Department of Justice (DOJ) has a strategic plan for 2018-2022. Which of the following is NOT included in the current strategy for the DOJ? a. Enhance national security and counter the threat of terrorism. b. Reduce violent crime and promote public safety. c. Promote rule of law, integrity, and good government. d. Ensure the privacy of patient records with the use of HIPAA

d. Ensure the privacy of patient records with the use of HIPAA Rationale: 1. Enhance national security and counter the threat of terrorism; 2. Secure the borders and enhance immigration enforcement and adjudication; 3. Reduce violent crime and promote public safety; and 4. Promote rule of law, integrity, and good government.

Dr. K was convicted of a crime and can no longer participate in the Medicare and Medicaid program. What is this referred to as? a. Discrimination b. Civil monetary penalty (CMP) c. False claims d. Exclusion

d. Exclusion Rationale: Congress mandated the exclusion of physicians and other providers convicted of crimes from participation in Medicare and Medicaid programs in 1977.

Physicians who negligently violate EMTALA are subject to civil monetary penalties and for repeated or gross and flagrant violations risk which of the following? a. Exclusion from board certification renewal b. Exclusion from malpractice coverage c. Exclusion from hospital on call privileges d. Exclusion from Medicare

d. Exclusion from Medicare

What does NOT need to be included in a notice of privacy practice (NPP)? a. A point of contact for further information and complaints b. Specific distribution requirements for providers and plans c. The provider's duties to protect PHI d. Explanation of the patient's treatment plan

d. Explanation of the patient's treatment plan

Which one is NOT subject to CLIA regulations? a. Urine pregnancy test in an ob-gyn office b. GI performs a fecal occult blood test c. Family practice office performing a finger-stick blood test d. Facility only doing urine collection for outside testing

d. Facility only doing urine collection for outside testing

The Fraud and Abuse Recovery Act (FERA) expands the grounds for liability under which act? a. Medicare Modernization Act b. Mail Fraud c. Racketeer Influenced and Corrupt Organization Act d. False Claims Act

d. False Claims Act

Fraud, waste, and abuse are all areas that must be controlled when providing services to beneficiaries. Which statement is TRUE regarding fraudulent billing? a. A series of errors is considered fraudulent billing. b. Fraudulent billing is only an issue if the erroneous billing is identified and not resolved. c. Fraudulent billing only occurs when refunds are not issued in a timely manner. d. Fraudulent billing is a willful act with intent to receive payment for services not rendered.

d. Fraudulent billing is a willful act with intent to receive payment for services not rendered. Rationale: Fraudulent billing is willful and is undertaken with the intent to receive payment for services not legitimately rendered.

HITECH revisions significantly increased the penalty amounts the Secretary may impose for violations of what? a. CLIA b. OSHA c. FCA d. HIPAA

d. HIPAA Rationale: These HITECH Act revisions significantly increased the penalty amounts the Secretary may impose for violations of the HIPAA rules, encouraging prompt corrective action.

The Office of Inspector General (OIG) has published compliance program guidance for which of the entities listed below? I. Laboratories II. Durable medical equipment providersIII. Home health IV. Hospice V. Small and large provider groups VI. Hospitals VII. Ambulance providers VIII. Nursing homes a. I, II, and III only b. I, III, V, and VII only c. I, III, IV, V, VI, and VIII only d. I - VIII

d. I - VIII Rationale: The OIG created the first compliance guidance in 1998 for Hospitals, Laboratory Compliance in 1998, DME (1999), Nursing Homes (2000), Provider Groups (2000 and 2003), Ambulance (2000 and 2003).

Which options are key elements for an effective compliance program? I. Conducting external auditing and monitoring. II. Implementing compliance and practice standards. III. Designating a compliance officer or contact IV. Outsourcing appropriate training and education. V. Responding appropriately to detected offenses and developing and implementing corrective action. VI. Developing open lines of communication. VII. Enforcing disciplinary standards through well-publicized guidelines. a. I-VII b. I-V, and VII c. II-VII d. II, III, and V-VII

d. II, III, and V-VII Rationale: There are seven elements in these guidelines that the OIG has stated are necessary in an effective compliance program: 1-Conducting internal monitoring and auditing 2-Implementing compliance and practice standards 3-Designating a compliance officer or contact 4-Conducting appropriate training and education 5-Responding appropriately to detected offenses and developing and implementing corrective action 6-Developing open lines of communication 7-Enforcing disciplinary standards 8-publicized guidelines

HIPAA requires national standards for code sets. Which of the following is NOT one of the standards required? a. HCPCS Level II codes b. ICD-10-CM codes c. CPT® codes d. ISO 9001 codes

d. ISO 9001 codes

Which factor is NOT considered in the OIG Work Plan? a. Mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directives. b. Requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget. c. Top management and performance challenges facing HHS. d. Inconvenience to the healthcare industry.

d. Inconvenience to the healthcare industry.

When a patient presents to an emergency room, the provider must not delay the screening process to ask about what? a. History b. Drug use c. Address d. Insurance

d. Insurance

Which of the following is not required in a written hazard communication program for the workplace? a. A list of hazardous chemical present b. Training on protective measures of hazardous material c. Distribution of safety data sheets d. List of prior hazardous material incidents

d. List of prior hazardous material incidents

The Medicare reassignment rules contain a number of exceptions governing who can bill the Medicare program. If a group practice is using a billing agent, what type of payment arrangement is necessary? a. Deposit to the billing agent b. Paper checks to the physician practice c. Direct checking account deposit d. Lockbox

d. Lockbox

Requirements for transferring an unstable patient do NOT include which one of the following? a. Physician must attest, in writing, that the medical benefits outweigh the risk of the transfer b. Consent of the receiving hospital c. Patient's condition must be documented d. Making sure patient has either Medicare or Medicaid

d. Making sure patient has either Medicare or Medicaid

Lim, a student that is studying for his CPCO, researches to find out what third-party healthcare provider is becoming a vital part of the healthcare industry. Which, of the below options, does he discover is relied on to submit claims correctly? a. Consultants b. Nursing facilities c. Clinical laboratories d. Medical billing companies

d. Medical billing companies Rationale: Providers have come to rely heavily on medical billing companies to submit their claims correctly.

A provider at the ABC Medical Group asked the compliance officer if CERT is involved with all Medicare, Medicaid, and TRICARE issues or only certain ones. How should the compliance officer respond? a. Medicare and Medicaid b. Medicare, Medicaid, and TRICARE c. Medicare Part C, Part D, and DMEPOS d. Medicare Part A, Part B, and DMEPOS

d. Medicare Part A, Part B and DMEPOS Response Feedback: Medicare Part A, Part B and DMEPOS. Each year, CERT evaluates a statistically valid random sample of claims (50,000 to date) to determine if CMS was paid properly under Medicare coverage, coding, and billing rules. A stratified random sample is taken by claim type as follows: Part A (excluding acute inpatient hospital services)Part A (acute inpatient hospital services only) Part B DMEPOS Claims selected on a semi-monthly basis MAC claims

The Office of Inspector General (OIG) has been at the forefront of the nation's efforts to fight fraud, abuse, and waste. A majority of the OIG's resources goes to oversight of which programs? a. Center for Disease Control (CDC) and Department of Labor (DOL) b. Center for Disease Control (CDC) and National Institutes of Health (NIH) c. U.S. Food and Drug Administration (FDA) and National Institutes of Health (NIH) d. Medicare and Medicaid (CMS)

d. Medicare and Medicaid (CMS)

Jackie is a coder and biller for ABC Provider Group. She often puts modifiers on various CPT® codes so that they can get paid, regardless of the documentation. What is this an example of? a. Professional courtesy b. A kickback scheme c. Billing to the best of your ability d. Misuse of modifiers

d. Misuse of modifiers

The two states that have mandatory compliance program certification requirements are_______________. a. New York and Vermont b. Virginia and Arkansas c. Arkansas and Vermont d. New York and Arkansas

d. New York and Arkansas

A person having an asthma attack presented to the physician office on the hospital campus. The office did not have a provider in the office and the patient had to go to the emergency department around the corner for treatment. Is the physician office in violation of EMTALA? a. Yes, the physician practice should have had a provider available. b. Yes, the physician practice is on the hospital campus. c. No, EMTALA does not apply because the physician was not in the office. d. No, EMTALA does not include physician practices.

d. No, EMTALA does not include physician practices.

A child arrives at the emergency department, appearing beaten. The patient's mother states the child was attacked by her spouse. The provider notifies the local police department. Is this a HIPAA violation? a. Yes, the provider must have the guardian's consent to release cases of child abuse. b. Yes, a provider cannot release PHI, under any circumstance, without the consent of the patient. c. No, PHI for a child is not covered under HIPAA. d. No, PHI can be released to the local police department in cases of child abuse.

d. No, PHI can be released to the local police department in cases of child abuse.

A board member of the Apple Internal Medicine Group wants to call the OIG hotline to "self-disclose." Is he allowed to do this? a. No; the OIG only allows faxed self-disclosure forms. b. Yes; the OIG allows all methods of self-disclosure. c. Yes; the OIG prefers the hotline for self-disclosures. d. No; the OIG does not allow self-disclosure via hotline.

d. No; the OIG does not allow self-disclosure via hotline.

Regulations state that services provided by teaching physicians in teaching settings are generally payable under the physician fee schedule only if the services are personally furnished by a physician who is what? a. A resident b. Not the chief of staff c. A fellow d. Not a resident

d. Not a resident

In addition to hospitals, what other type of facility did the OIG provide supplemental compliance program guidance for? a. Ambulance Suppliers b. Medicare Choice Organizations c. Physician Practices d. Nursing Facilities

d. Nursing Facilities

Which entity enforces the HIPAA Privacy Rule? a. HHS b. OIG c. DOJ d. OCR

d. OCR

Which office provides guidance to the healthcare industry in the form of advisory opinions, special fraud alerts, special advisory bulletins, and compliance program guidance? a. CMS b. MAC c. Attorney General d. OIG

d. OIG

Which office's main responsibility is it to investigate healthcare fraud, waste, and abuse? a. CMS b. MAC c. Attorney General d. OIG

d. OIG

Which office listed below is NOT addressed in the OlG Work Plan? a. Office of Investigations b. Office of Evaluation and Inspections c. Office of Audit Services d. Office of Health and Human Services

d. Office of Health and Human Services The OIG Work Plan includes projects to be addressed during the fiscal year (and beyond) by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The entire current Work Plan or sections of the plan can be downloaded at the OIG's website at https://oig.hhs.gov/reports-and-publications/workplan//.

Which component of the OIG operates the OIG hotline? a. Office of Counsel to the Inspector General b. Office of Management & Policy c. Office of Evaluations & Inspections d. Office of Investigations

d. Office of Investigations Rationale: Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. The OI also operates an OIG hotline.

What records should you submit when a claim is being audited? a. Every record on file. b. Every record that pertains to the service in question. c. You do not need to heed a record request from anyone other than CMS. d. Only the records for the date of service requested need to be submitted.

d. Only the records for the date of service requested need to be submitted

Which entity below could NOT bill for medically unnecessary services? a. Hospitals b. Physicians c. Ancillary providers d. Patients

d. Patients Rationale: There is tremendous pressure to contain healthcare costs, and government payers necessarily must be on guard against hospitals, physicians, and ancillary providers billing for wasteful or medically unnecessary services.

Which scenario falls under EMTALA? a. Young man comes to see his primary care physician's office with abdominal pain and vomiting b. Elderly man comes into the cardiologist's office with chest pressure c. Young child comes into the Quick Care of the ER with only a sore throat d. Pregnant patient comes into the ER having contractions

d. Pregnant patient comes into the ER having contractions

What does Part D cover? a. Skilled nursing b. Durable medical equipment c. Hospital d. Prescription drugs

d. Prescription drugs

What defines and limits the circumstances in which an individual's PHI may be used or disclosed by covered entities? a. Constitution b. First Amendment c. OIG d. Privacy Rule

d. Privacy Rule

What is more important to have in place for enforcing and disciplining individuals who violate the practice's compliance program or other practice standards? a. Meetings b. Training c. Rules d. Procedures

d. Procedures Rationale: There should be procedures for enforcing and disciplining individuals who violate the practice's compliance or other practice standards. All employees, regardless of rank, need to be held accountable for non-compliance of federal regulations.

What is another quality standard which goes with patient test management, quality control, personnel qualifications, and quality assurance that CLIA specifies? a. Waived testing b. Quality assurance testing (QAT) c. Billing Medicare and Medicaid d. Proficiency testing (PT)

d. Proficiency testing (PT)

The Civil Monetary Penalty Law and the False Claims Act are related to which one of the following? a. Mail fraud b. Racketeer Influenced and Corrupt Organization Act c. Improper inducements d. Proper claims filing

d. Proper claims filing Two laws, the Civil Monetary Penalty Law and the False Claims Act, are related to proper claims filing. Mere mistakes, which can be remedied by returning overpayments, does not result in violations of these laws.

Who can detect and correct past improper payments so that CMS and carriers, fraud investigators? a. OIG b. CMS c. MAC d. RACs

d. RACs Rationale: RACs detect and correct past improper payments so that CMS and carriers, fraud investigators, and then MACs can implement actions that will prevent future improper payments. In turn, providers can avoid submitting claims that do not comply with Medicare rules; CMS can lower its error rate; and taxpayers and future Medicare beneficiaries are protected from fraud.

Under EMTALA, when are all participating hospitals required to provide at least a medical screening exam to a patient who comes to the emergency department? a. Only if the patient has Medicare Part A. b. Only if the patient has Medicare Part B. c. Only when the patient is uninsured. d. Regardless of the patient's insurance or ability to pay.

d. Regardless of the patient's insurance or ability to pay.

Which one of the following federal regulations is NOT pertinent to billing companies? a. False Claims Act b. Patient Protection and Affordable Care Act c. Health Insurance Portability and Accountability Act d. Safe Harbor Rules

d. Safe Harbor Rules

The OIG's __________________ to Congress keeps the Secretary of the HHS and Congress currently informed about OIG's most significant findings, recommendations and activities monthly. a. Fiscal Year Report. b. Annual Work Plan. c. Audit Report. d. Semi-annual Report

d. Semi-annual Report Previously, OIG updated its Work Plan to reflect adjustments once or twice each year. In order to enhance transparency around OIG's continuous work planning efforts, effective June 15, 2017, OIG will update its Work Plan website monthly to HHS and Congress current on significant findings.

On what date were all covered entities required to comply with HIPAA Omnibus Rules? a. January 23, 2013 b. March 13, 2014 c. March 15, 2014 d. September 23, 2013

d. September 23, 2013

An emergency medical condition is defined as having symptoms (including severe pain and psychiatric disturbances) such that the absence of immediate medical attention could result in which of the following? a. Being brought to the hospital by ambulance b. Loss of wages for not being able to work c. Serious comorbidities developing in the future d. Serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part

d. Serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part

Kim, at Apple Hospital, is explaining to her compliance committee the components required by the OIG to have an effective compliance program. How many components does she tell them that are key factors? a. Five b. Three c. Six d. Seven

d. Seven

What safeguards are defined as measures to protect ePHI? a. Facility safeguards b. Administrative safeguards c. Physical safeguards d. Technical safeguards

d. Technical safeguards

Because of the changing nature of healthcare regulation, which statement is TRUE regarding updating the compliance program? a. The compliance program should only be updated annually to ensure all the changed regulations are captured. b. The compliance program should be updated biannually. c. Hiring a consultant to review the program for accuracy is necessary. d. The compliance program should be continually a work in progress.

d. The compliance program should be continually a work in progress. Rationale: The program should be monitored and updated at least annually, and more likely more often, to provide for up-to-date compliance.

What does the term "disclosure" mean? a. Authorizing the release of medical records b. Authorizing the release of PHI c. The release or transfer of information d. The release or transfer of information to an outside entity

d. The release or transfer of information to an outside entity

Tom creates a compliance program training for his staff. The training includes the operation and importance of the compliance program and the consequences of violating the standards and procedures set forth in the program. Which of the following should also be included in the training? a. An organizational chart for the employees in the organization. b. The job description for each employee in the organization. c. The role of each department manager in the operation of the training program. d. The role of each employee in the operation of the training program.

d. The role of each employee in the operation of the training program. Rationale: Typical topics will include the operation and importance of the compliance program, the consequences of violating the standards and procedures set forth in the program, and the role of each employee in the operation of the compliance program.

During the monthly new hire training, the compliance officer for Apple Hospital explains that, as an element of a billing and reimbursement, the compliance program is essential. Employees must be aware of the compliance issues and the applicable laws and regulations, especially those that pertain to what? a. The medical record department b. OSHA c. HIPAA d. Their specific job descriptions

d. Their specific job descriptions

Which of the following is a pertinent component of an effective compliance program? a. Reporting all suspected fraud to HHS immediately b. Credentialing providers on a timely basis c. Meeting deadlines d. Training and educating employees

d. Training and educating employees

John is the compliance officer for ABC Internal Medicine Group. What does he tell the board of directors is the key factor in the prevention of OSHA injuries and illnesses? a. Drug testing b. HR screening c. Keeping the floors clean d. Training and education

d. Training and education

PHI may be disclosed without the patient's authorization for ___________________. a. Death, operations, and birth certificates b. Treatment, pictures, and operations c. Injections, shots, and research d. Treatment, payment, and operations

d. Treatment, payment, and operations

Which agency is responsible for the oversight of the Medicare and Medicaid programs? a. Office of Inspector General b. U.S. Attorney's Office c. Office of Civil Rights d. U.S. Department of Health & Human Services

d. U.S. Department of Health & Human Services

_________ is billing for a more expensive service than the one actually performed. In the hospital setting, ______ is in the form of using higher rated (paying) diagnostic related group (DRG) codes. The same can happen in surgical procedures, therapy services, radiology, and laboratory services. a. Code Creep b. Clustering c. Double Billing d. Up-Coding

d. Up-Coding

When does an employee's declination of hepatitis B expire? a. When other employees are at risk b. When the employee has an incident c. When the employer finally mandates the vaccine d. Whenever the employee decides to get the vaccine

d. Whenever the employee decides to get the vaccine

Hannah is afraid that if she reports the allegation of fraud that she thinks is occurring at her medical office that she will be fired. Could this occur? a. No. The employer can only demote or suspend her. b. No. There needs to be grounds for all job terminations. c. Yes. The employer has the right to terminate her under any circumstances. d. Yes, but the employer would be in violation of the Whistleblower Protection Law.

d. Yes, but the employer would be in violation of the Whistleblower Protection Law.

The front office assistant at ABC Internal Medicine Group asked the compliance officer, John, if she is allowed to release requested information to the court. How should John reply? a. No, not unless there is a signed consent by the patient. b. Yes, if an attorney signs the release, then the information can be released. c. No, not unless the patient stipulated such action in their original statement to the office. d. Yes, if there is a subpoena.

d. Yes, if there is a subpoena. Yes, if there is a Subpoena. Under 45 CFR 164.512(e)(1)(ii) of the Privacy Rule, a covered entity that is not a party to the litigation may disclose protected health information in response to a subpoena, discovery request, or other lawful process if the covered entity receives certain satisfactory assurances from the party seeking the information.

Should providers learn about Medicare guidelines? a. No, their coders can learn about the Medicare guidelines. b. No, that is why they have a compliance program. c. No, that is why they hire billers. d. Yes, they are obligated to under law.

d. Yes, they are obligated to under law.

Larry is the compliance officer for Orange County Family Medicine Group. The board of directors wants to use the list of patients to send out information regarding a fund raiser. What does Larry tell the board of directors? a. No; patient information is confidential. b. Yes; as long as the hospital is doing it for charity. c. No; HIPAA prohibits this. d. Yes; if a covered entity's notice of privacy practices provides that the entity may contact the patient for fundraising and the patient has a right to opt-out of fundraising communications, then permitted fundraising PHI may be used for fundraising communications.

d. Yes; if a covered entity's notice of privacy practices provides that the entity may contact the patient for fundraising and the patient has a right to opt-out of fundraising communications, then permitted fundraising PHI may be used for fundraising communications.

When an organization offers another organization incentive for referrals, what is this referred to? a. common practice b. ethical standard c. fair trading practices d. improper inducements

d. improper inducements Rationale: Improper inducements are when an organization or individual offers another organization or individual an incentive for the referral of potential clients or patients. An incentive may take the form of cash, non-cash gifts, providing services for the benefit of the referral source or making reciprocal referrals.

A person studying for the CPCO should review compliance guidance for ______________. a. only the small group physician practices. b. third-party billing companies, clinical laboratories and hospitals only. c. hospitals and individual and small group physician practices only. d. individual and small group physician practices, third party billing companies, clinical laboratories, and hospitals.

d. individual and small group physician practices, third party billing companies, clinical laboratories, and hospitals.

ABC Provider Group and Apple Medical Group agree to pool their resources for the purpose of accomplishing a specific task. What is this called? a. help maintain cost of practice b. fraud c. sharing expenses d. joint ventures

d. joint ventures