CPCO chapter 1

What does LEP stand for?

LEP

What office is responsible for the HIPAA privacy rule

Office of civil rights

Which entity below could NOT bill for medically unnecessary services? Answers: Hospitals Physicians Ancillary providers Patients

Patients

Which HHS Title is the Limited English Proficient Persons (LEP) requirement covered under? V VI VII II

VI LEP Strategic Plan to improve access to HHS Programs and Activities by Limited English Proficient Persons (LEP) came about in December 2000 - Title VI.

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? Center for Disease Control (CDC) and Department of Labor (DOL) Center for Disease Control (CDC) and National Institutes of Health (NIH) U.S. Food and Drug Administration (FDA) and National Institutes of Health (NIH) Medicare and Medicaid (CMS)

Medicare and Medicaid (CMS) A majority of the OIG's resources goes toward the oversight of Medicare and Medicaid programs, meant to help this country's most vulnerable citizens (those either disabled, underprivileged, or over the age of 65) that also happen to represent a significant part of the federal budget.

CPUP was the first large fraud case that involved a teaching hospital where Residents and Fellows worked. Where is CPUP located? Michigan Boston New York Pennsylvania

Pennsylvania The clinical practices of the University of Pennsylvania (CPUP) was the first major audit that targeted teaching hospitals in 1995.

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

Regularly review and update the compliance program.

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

Ensure the privacy of patient records with the use of HIPA The strategic plan for 2018-2022 for the DOJ includes:•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.HIPAA and patient records are not part of this strategy.

Dr. K was convicted of a crime and can no longer participate in the Medicare and Medicaid program. What is this reffered to as Discrimination Civil Monetary Penalty (CMP) False Claims Exclusion

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

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)? One year. Three years. Five years. Seven years.

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

Which department is the largest inspector general's office in the federal government? Answers: HHS Office of Inspector General Office of Civil Rights Department of Justice Centers for Medicare & Medicaid Services

HHS Office of Inspector General

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

Help create financial success, customer loyalty, community support, and employee satisfaction. 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.

Which of the following is NOT one of the 7 Elements of an Effective Compliance Program? Conducting internal monitoring and auditing Hiring legal counsel Implementing compliance and practice standards Designating a Compliance Officer or contact Conducting appropriate training and education Responding appropriately to detect offenses and developing and implementing corrective action Developing open lines of communication Enforcing disciplinary standards through well publicized guidelines

Hiring legal counsel The seven elements are part of the Federal Sentencing Guidelines. The seven elements are part of each of the OIG's Compliance Program. Legal Counsel is not one of the seven elements.

The Office of Inspector General (OIG) has published Compliance Program Guidance for which of the entities listed below? I. Laboratories II. Durable Medical Equipment providers III. Home Health IV. Hospice V. Small and Large Provider Groups VI. Hospitals VII. Ambulance providers VIII. Nursing Homes I, II, and III only I, III, V, and VII only I, III, IV, V, VI, and VIII only I - VIII

I - VIII 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).

The Federal Sentencing Guidelines (FSGs) are rules that set out a uniform sentencing policy for those convicted of felonies and serious (Class A) misdemeanors in the United States federal courts system. In healthcare, the FSGs are used as the core elements for which of the following? I. The OIG's Five-principle Strategy to combat healthcare fraud, waste, and abuse. II. The seven core elements of an effective compliance program. III. The core elements of corporate integrity agreements. IV. The final rule for the Medicare Access and CHIP Reauthorization Act (MACRA). V. The False Claims Act (FCA). I and II II and III III and IV IV and V

II and III The compliance program guidance is recognized by the United States Sentencing Commission (USSC). These seven core elements are used by the USSC as the basis for the FSGs for healthcare offenses. The core elements of CIAs were created around the 1995 Federal Sentencing Guidelines (https://oig.hhs.gov/publications/docs/retrospective/AnniversaryPub.pdf).

In what year did the OIG post guidance for hospitals? 1996 1997 1998 1999

1998

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

2010 The Patient Protection and Affordable Care Act was signed by President Obama on March 23, 2010. The Patient Protection and Affordable Care Act of 2010 (PPACA) indicates compliance programs will become mandatory as a condition of enrollment in the federal healthcare programs, a requirement confirmed by Daniel R. Levinson of the Office of Inspector General (OIG) in his testimony to the House Committee on Energy and Commerce, Subcommittee on Health on September 22, 2010.

What term would be used for actions that, either directly or indirectly, results in unnecessary costs to the Medicare program? Fraud Mistake Waste Abuse

Abuse

What is considered a significant element in committng an act of fraud? Billing for services performed Reviewing OIG Exclusions Using the Compliance Guidance as a guide for your practice Knowingly and Intent

Knowingly and Intent Fraud has several definitions. Under HIPAA, fraud is defined as "knowingly, and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program." The key term is knowingly. Abuse is similar to fraud, except that the investigator cannot establish the act was committed knowingly, willfully, and intentionally. The difference between fraud and abuse is theindividual's intent; however, both have the same impact in that they steal valuable resources from the healthcare industry.

The OIG has stated that an effective compliance plan can help create which of the following? customer loyalty, a need for refunds, and overpayments from insurance carriers. community support, financial success, wealthy physicians. financial success, flawless billing, and lessen staff required to support the practice. customer loyalty, community support, and financial success.

customer loyalty, community support, and financial success. The OIG has stated that an effective compliance program can help create financial success, customer loyalty, community support, and employee satisfaction.

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

The OIG guidance documents utilize the seven elements of the Federal Sentencing Guidelines as the basis of an effective compliance program.

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? Vigilantly monitor programs for evidence of fraud, waste, and abuse. Establish compliance officers for each healthcare provider's office. Scrutinize compliance plans to ensure all compliance plans are uniform and unaltered. Respond swiftly to natural catastrophies.

Vigilantly monitor programs for evidence of fraud, waste, and abuse. Rationale: The OIG's Five-principle Strategy to combat healthcare fraud, waste, and abuse include: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; and5 - Response - respond swiftly to detect fraud, impose sufficient punishment to deter others, and promptly remedy program vulnerabilities

Dr. X is a very thorough provider. He always runs a full blood panel on each patient every year for their physical, regardless of the health of the patient. This is an example of: Fraud Abuse Waste Misuse of resources

Waste Medicare defines waste as a medically unnecessary service. An example of waste given by CMS is a provider who orders a lab panel instead of just ordering the one lab test that is needed.

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? No, it is considered waste. Yes, it is considered fraud. No, it is considered abuse. Yes, only because lab services owned by providers is a special category so therefore it is fraud.

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

Kathy, the Compliance Officer at a small provider office, is notified that a patient with limited english proficiency (LEP) is on the schedule and will need an interpreter. According to the LEP requirements, an interpreter should be provided: for a small fee to the patient. for a small fee to the insurance carrier. at no cost to the patient. An interpreter is not required.

at no cost to the patient A LEP person/patient who needs an interpreter to translate to and from the person's primary language must have one provided at no cost to the patient.

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

Compliance plans need to be tailored to fit the unique needs of every organization or physician practice. 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.

Which government department is comprised thousands of employees who enforce the nation's federal criminal laws and help develop and implement criminal law policies? Office of Inspector General Centers for Medicare & Medicaid Services Health Care Lawyers Association Department of Justice

Department of Justice. 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? Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention U.S. Food & Drug Administration Drug Enforcement Agency

Drug Enforcement Agency. 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). DEA is overseen by DOJ.

The Office of Evaluation and Inspections is part of what Agency or Department? Department of Justice Department of Audits Office of Inspector General Centers for Medicare & Medicaid Services

Office of Inspector General The OIG consists of 6 departments. One of these is the Office of Evaluations and Inspections.

Which component of the OIG operates the OIG Hotline? Office of Counsel to the Inspector General Office of Management & Policy Office of Evaluations & Inspections Office of Investigations

Office of Investigations 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.

Which OIG office conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries? Office of Evaluations and Inspections Office of Management and Policy Office of Investigations Office of Counsel to the Inspector General

Office of Investigations The 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.

Dr. Smith had some billing issues at his medical office. He agreed to work with the OIG to correct the issues. What does the term "CCA" refer to so that you (the Compliance Officer) can explain to Dr. Smith?

Certification of Compliance Agreement in which providers agree to continue to operate their existing compliance program.

When working with Corporate Compliance, what does the acronym CCA refer to? Certification of Compliance Agreement in which providers agree to hire a certified professional to oversee compliance of the organization. Certification of Compliance Agreement in which providers agree to continue to operate their existing compliance program. Certification of Coding Agreement in which providers agree to hire a certified coder to code all services. Certification of Coding Agreement in which providers agree to hire a certified coder to perform periodic audits of coding.

Certification of Compliance Agreement in which providers agree to continue to operate their existing compliance program. The acronym CCA stands for Certification of Compliance Agreement which requires providers to certify that they will continue to operate their existing compliance programs for a fixed term.

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? Yes, as long as the nurse pays a CMP. No, Dr. X will receive a CMP for hiring an excluded individual. Yes, as long as the nurse only assist with Medicare patients. No, the nurse may not work for anyone who sees Medicare Beneficiaries ever again.

No, Dr. X will receive a CMP for hiring an excluded individual. 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.

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? Employment Equality Agency Office for Civil Rights Department of Justice Office of Inspector General

Office for Civil Rights

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

Office of Audit Services The Office of Audit Services performs independent audits of HHS programs and/or HHS grantees and contractors to examine their performance.

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

Office of Civil Rights The OIG Consists of six departments: Immediate OIG Office of Audit Services Office of Evaluation and Inspections Office of Management and Policy Office of Investigation (OI) Office of Counsel to the Inspector General

In addition to hospitals, what other type of facility did the OIG provide supplemental compliance program guidance for?

Supplemental compliance program guidance was published for nursing facilities in September 2008.