CPCO STUDY GUIDE
Hospitals are prohibited from making payments, directly or indirectly, to a physician as an inducement to reduce or limit services provided to Medicare or Medicaid patients. The hospital is subject to a civil money penalty of not more than how much for each individual for whom a payment is made?
$2,000
The Office of Civil Rights (OCR) has enforcement power for violations occurring as a result of willful neglect. The OCR can now impose civil monetary penalties of up to how much per HIPAA privacy regulations violation.
$50,000
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?
$50,000, and an assessment of three times the amount of the kickback
CMS is headquartered in Baltimore and has ________ regional offices around the country, which primarily oversee enrollment and certification issues.
10
Employers with fewer than __________ employees are exempt from the federal OSHA record keeping requirement.
10
How many states require nursing facilities to perform a FBI checks on employees?
10
Penalties for mail fraud where the person knowingly and willfully schemes to defraud a health care benefit program includes fines and imprisonment of up to how many years?
10 years
The CMP Inflation Adjustment increased the maximum penalty amount per false claim to?
10,781-$21,563, plus the assessment of not more than three times the amount claimed for damages
Under the Federal Guidelines, a person may take up to ________ weeks off for FMLA:
12
In a qui tam action in which the government intervenes, the relator is entitled to receive a monetary settlement between?
15-25% (if govt internvenes) 25-30% (if govt declines to intervene)
Under COBRA the employer must permit qualified beneficiaries to elect to continue their health insurance under their current plan for up to _______ depending on the qualifying event.
18, 29, 36 months
What year did OSHA publish the Bloodborne Pathogens Standard?
1991
What year did the GAO identify Medicare claims to be at high risk for fraud and abuse which resulted in the OIG initiating an audit of HCFA (CMS) payment system?
1992
In what year did the OIG post guidance for hospitals?
1998
If an internal audit reveals issues, it's time to do some interviews and document reviews. How many people should be involved in the interview process of an employee?
2
CLIA certificates are valid for how long
2 years
Penalties for mail fraud that results in bodily injury include fines and imprisonment of up to?
20 years
Comprehensive Error Rate Testing Program (CERT) started in what year?
2001
When did the Needle Stick Safety and Prevention Act become effective?
2001
The Medicare Learning Network (MLN) began in ________
2004
The nationwide network of MACs dates back to ________.
2006
What year was the ADA amendment enacted?
2008
What year did HITECH Act get implemented?
2009
OSHA requires that the employer report to OSHA all in-patient hospitalizations that were work related to OSHA within ___________.
24 hours
Sofie works at Apple Rural Health Center. Here husband just returned from active duty and was injured- she needs to take of time to get the house hold stabilized. How much time can Sofie take off?
26 weeks
After initial education and training have been implemented, what does the OIG recommends a benchmark audit be performed?
3 months
Changes in ownership must be reported within how many days to the Medicare program?
30
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
30
After enacting CLIA, what percentage did the total number of quality deficiencies decrease from the first laboratory survey to the second?
40%
Which Code of Federal Regulation section is important to Compliance Officers and why?
42; it covers the Medicare and Medicaid programs
How many states currently require nursing facilities to perform a background check of state records for direct-access employees?
43
How many employees does an employer need to not be held to FMLA policies?
49 or less
Patient Records of patients that have died are protected for how many years?
50 years
How many regions are part of the Medicaid Fraud Control Unit?
6
How many years should providers keep track of disclosures?
6 or more years
The medical records department at Apple Rural Health Center asks Kim, the Compliance Officer how far back do they need to go to give a patient an accounting of the PHI disclosures on their account? Kim answers:
6 years
A qui tam complaint is initially sealed for how many days?
60
The ACA requires providers to refund an overpayment to Medicare within how many days of identification?
60
The Patient Protection and Affordable Care Act (PPACA) enacted a civil monetary provision that requires the return of overpayments within how many days of identifying an overpayment?
60
What is the maximum amount of days after determining that there is credible evidence of fraudulent conduct should a billing company take to notify federal and state authorities regarding the violation?
60
Payers expect all providers to refund monies that are overpayments. By law, this must occur within.....
60 days of identification of overpayment.
How many percutaneous injuries involving contaminated sharps occur annually?
600,000
OSHA requires that employers report to OSHA all work related fatalities within _________
8 hours
Because it is such a large component of their responsibility, what percentage of resources does OIG dedicate to Medicare and Medicaid?
80%
What percentage of OIG's resources are historically directed towards Medicare and Medicaid?
80%
Physicians need to report any change in their name, taxpayer identification numbers, and bank arrangement within how many days?
90
When is the recommended timeframe for a performance review?
90 days
Medicare requires that physicians or mid-level (NPP) 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 _____ days.
90 or 30
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 (CO), Kim should implement what type of compliance model?
A "patients first"
Skilled Nursing Facilities (SNFs) are Medicare certified facilities that provide extended skilled nursing or rehabilitative care under Medicare Part ____.
A and B
The OIG takes into consideration severity and extent of the underlying misconduct, the nature and resources of the provider, the provider's existing compliance capabilities, and whether the case resulted from a self-disclosure are all relevant factors considered in crafting what?
A corporate integrity agreement
What is OSHA?
A federal agency in charge of employee safety
The Anti-Kickback Statute
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 utilizes their product • A physician who is paid exorbitantly for speaking engagements by a company to whom the provider refers business
Which of the following is NOT an example of safety measures?
A security alarm system with same access ID for everyone
Fraud waste and abuse are all areas that must be controlled when providing services to beneficiaries. Fraudulent billing is:
A willful act
Fraud, waste, and abuse are all areas that must be controlled when providing services to beneficiaries. Fraudulent billing is:
A willful act.
Kim is the Compliance Officer for a large provider group. One of the billers for the group enters codes from the encounter form every evening before she goes home and then finishes in the morning when she returns. She often enters an encounter twice. She usually catches the mistake when the insurance checks are sent to the office and returns the overpayment to the insurance carrier. This is an example of:
Abuse
What term would be used for a practice that, either directly or indirectly, results in unnecessary costs to the Medicare program?
Abuse
If physicians sign a participating (PAR) agreement with Medicare, they agree to what?
Accept Medicare's allowed charge as payment in full
What is one way to discourage whistleblowers?
Acknowledge previous concerns in writing and explain investigation
What safeguard covers 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?
Administrative safeguards
What is considered an appropriate start to implementing an effective compliance program for compliance officers of small physician group practices with limited resources?
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?
Form CMS-R-131 is better known as?
Advance Beneficiary Notice of Non-Coverage
What should be readily accessible to all coding staff?
All essential coding resources
The OIG defines the term "reportable event" in its CIA by noting that it could be:
All of the above
Under EMTALA a treating physician can consult other physicians in what ways that are not prohibited?
All of the above
What is required on all CMS-1500 forms when billing for laboratory testing?
All of the above
What are designated health services?
All of the above (clinical laboratory, physical therapy, home health services)
Joan is the Compliance Officer for XYZ Community Hospital. She gives OSHA Blood Borne Pathogens training to all of the following groups or people:
All paid and non-paid workers at XYZ that might come into contact with Blood Borne Pathogens
Where can a Compliance Officer from a family practice look for information on risks specifically associated with his/her practice type?
American Academy of Family Physicians
Health Information Technology for Economic and Clinical Health Act (HITECH), which was enacted as part of the _________.
American Recovery and Reinvestment Act
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 what statute?
Anti- Kickback
What area is of concern when patients are referred to home health agencies and/or DME suppliers?
Anti-Kickback
If a group pays a hospital monthly rent for office space that is one-half of the going rate or fair market value, this is a violation of which regulation?
Anti-Kickback Statue
In certain cases, a provider, practitioner or supplier who routinely waives Medicare copayments or deductibles also could be held liable under what law?
Anti-Kickback Statue
Judy is the front office assistant at XYZ Family Practice Group. She wants to know why she can't waive co-pays on a regular basis if the patient can't pay. Routine waiver of co-payments or deductibles for patients under Medicare Part B is in violation of what Statute?
Anti-kickback
Who can initiate a Qui Tam action?
Any private party with independent knowledge of wrongdoing may
Who cannot be a violator of fraud?
Anyone can be a violator of fraud
How often should the Tim, Compliance Officer for XYZ Community Hospital update the compliance program and plan?
As laws and regulations change; and at least annually
Which of the following is NOT an example of sexual harassment?
Asking another employee to date
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:
Association of Healthcare Internal Auditors (AHIA)
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?
At any time
Work the attorney does in creating reports, interview memos, or research is called what?
Attorney-client work-product
Mary is the Compliance Officer for Apple Community Hospital. Mary asks the Billing Manager to remind her of the two types of Recovery Audit Contractor (RAC) reviews. The answer is _______________________________________.
Automated and Complex
RACs perform what type of reviews?
Automated and complex
Why is the annual OIG Work Plan so important to Compliance Officers when they are developing their risk assessments?
Because it shows results of previous year's audit findings and the current year's focus
Why did OSHA publish a Bloodborne Pathogens standard?
Because of significant exposures to viruses and other microorganisms
What timeframe is an employer required to post the OSHA 300?
Between February 1st and April 30th
Which of the following is NOT true regarding how improper payments are categorized?
Billed Based on Time
What third party plays a critical role in accurate billing and reimbursement?
Billing agencies
What is NOT a typical way that providers try to defraud Medicaid?
Billing under several NPIs at a time
The National Fire Protection Association (NFPA) states that products that are a physical or chemical hazard must be marked with the colors _____________:
Blue, Red, Yellow, White
Which person can receive records of Minors with Custodial / Non-Custodial Parents?
Both parents have legal rights, unless ordered by judge otherwise
When an individual makes a request for an accounting of disclosures, the accounting for each disclosure must include _________________________________________.
Brief statement of purpose that reasonably informs the individual of the purpose or a copy of the authorization or a copy of the written request for disclosure
Deficit Reduction Act (DRA) requires that providers who have more than $5 million either received or paid to the reimbursement from state Medicaid programs inform employees of their ability to ____________________________?
Bring a whistleblower action
Tim, the Compliance Officer for XYZ Community Hospital, should report to whom?
CEO or Board
To avoid a conflict of interest, the OIG specifically states that the compliance officer should not report directly to whom?
CFO
Who conducts inspections and enforces regulatory compliance for CLIA?
CMS
________ publishes the CLIA rules and regulations.
CMS
____________ provides opinions for the Stark Law
CMS
A participating hospital is required to keep a ______________ ____________ on each individual who comes to the emergency department seeking assistance, whether or not that person refused treatment, was refused treatment, admitted and treated, stabilized and transferred or discharged.
Central log
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 be in compliance with the CLIA regulations?
Certificate of Registration
To enroll in the CLIA program, laboratories must first register by completing an application, pay fees, be surveyed, if applicable and become what?
Certified
Lon, the billing manager, sometimes uses the term "double billing". What does this phase refer to?
Charging the patient for a membership fee to see the provider as well as billing for the actual office visit that day.
Which president signed the Family Medical Leave Act (FMLA)?
Clinton
John is the Compliance Officer for ABC Medical Group. One of the providers asks him what does the acronym CERT stand for? John replies:
Comprehensive Error Rate Testing
What is one way to discourage whistleblowers found in this chapter?
Conduct performance reviews
Which one of the following is NOT a corrective action resulting from an audit?
Conducting educational sessions for provider and all clinical staff
If a state or federal agent arrives at your office and presents a search warrant, it is best practice to what?
Contact your attorney immediately
Requisition Lab slips should do all EXCEPT the following:
Contain a statement that indicates Medicare generally covers all routine screening tests
John, Compliance Officer at ABC Internal Medicine Group, explains to the front office staff that release of information authorizations must:
Contain an expiration date and a statement regarding right to revoke.
Medical practices should be aware of risks identified in the past and then establish policies and procedures for what?
Continual monitoring
What are the key functions of the Compliance Officer with regard to planning, implementing and monitoring the compliance program?
Coordination and communication
John works at a large hospital in the Compliance Department. He just heard that the hospital was issued a CIA. What does CIA stand for?
Corporate Integrity Agreement
What is it called when the OIG waives its exclusion authority concurrent with resolution of monetary liability under the False Claims Act and the CMP Law?
Corporate Integrity Agreement
The Yates Memo of 2015 considers what factors?
Corporate wrongdoing
The Compliance Officer is responsible to find areas of non-compliance and then formulate solutions to rectify the problems. This is known as what?
Corrective Action Plan
Which of these responsibilities is not one of a Compliance Officer?
Create all policies and procedures
What type of software process identifies potential claim errors?
Data mining
Health information that does not identify an individual is called _______________.
De-identified Information
Which government department is comprised of thousands of employees who enforce the nation's federal criminal laws and help to develop and implement criminal law policies?
Department of Justice
Larry is the Compliance Officer for a small hospital. A staff member of the hospital thinks that employment discrimination has occurred. Which governmental office could give Larry more information?
Department of Labor
Steve, Director of Compliance for Small Rural Hospital Group explains to the physicians that some of the most common reasons for claims not being paid in the current reimbursement environment are related to _______
Diagnosis Code
Key risk areas defined for third-party medical billing companies for the OIG Compliance Program Guidance include all listed except:
Diagnosis-related group (DRG) creep
What should never be tolerated by an employer?
Discrimination
Dr. A hires a nurse without looking to see if she was on the OIG's Excluded List. The nurse had committed fraud in the past and was Excluded from working with any entity or individual that uses Federal or State funds. Which of the statements below is true?
Dr. A will have to pay a CMP
Which federal government department is the OIG not responsible for overseeing?
Drug Enforcement Agency
Kim, Compliance Officer at Apple Rural Health Center, authorizes a drug screen to be done on an employee that she feels is impaired. The employee states that this is discrimination.
Drug screens can be done on an employee if there is reasonable suspicion that the employee is impaired.
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?
EMTALA
Typically, document reviews are done ________, and the government will ask for ______.
Electronically, electronic files
n an internal investigation it is important to communicate to employees that it is against policy to destroy or remove any documentation from a patient's medical record. Document reviews can be extensive and may involve:
Emails, mobile phone calendars, and notes
What is an EAP?
Employee Assistance Plan
A Board member at the XYZ Community Hospital inquires what the term EAP refers to?
Employee Assistance Plans
What is not included in the Hazard Communication Standard?
Employee training on evacuation routes
What employees fall under Category III?
Employees not exposed to blood borne pathogens
Why should compliance officers have set disciplinary policies for non-compliance?
Employees should know the consequences for non-compliance of set policies
What can employers do to increase employee engagement?
Employers should hold management accountable for engagement
What would require a high-level disinfection?
Endoscope
Which of the following is considered the primary means of minimizing employee exposure?
Engineering controls
OSHA requires that the employer displays the OSHA poster in:
English
The OIG Five Principal Strategy is made up of the following
Enrollment, Payment, Compliance, Oversight and Response
Steve at Orange Laboratories wants to make sure that the lab stays in compliance with OIG guidelines. Steve will make sure that the following DOES NOT Occur EXCEPT:
Ensure that there is a completed ABN
The current strategy for the DOJ includes all of the following except:
Ensure the privacy of patient records with the use of HIPAA
What employees DO NOT fall under Category II?
Environmental services personnel
Kim, Compliance Officer for Apple Rural Health Center explains to the Board that EEOC is referred to in the HR policy and stands for:
Equal Employment Opportunity Commission
Judy at Apple Medical Group wants to know why Hot Line allegations should be tracked?
Establish patterns or trends that need to be followed
What does not need to be included in a Notice of Privacy Practice (NPP)?
Explanation of the patient's treatment plan
The ________ is one of the primary investigation agencies that assist the federal prosecutors.
FBI
Tim is the Compliance Officer for the Apple Internal Medicine Group. He conducts the in-service training for all new employees. He discusses the 5 most important federal fraud and abuse laws. These are:
FCA, AKS, Stark, Exclusion, CMPL
Department of Labor requires compliance with employee and employer laws including:
FLSA, OSHA, CRA, ERISA
Clinical Laboratories should charge physicians a price for ordered tests at _________________________
Fair market value
FERA expands the grounds for liability under which Act.
False Claims Act
Kim, the Compliance Officer at Apple Rural Health Center, must report the OSHA incidents on Form 301 every year between the months of ___________________________________?
Feb-April 30th
Federal government agencies such as HHS, CMS, and the OIG publish regulations in the ___________________>
Federal Register
The OIG has described seven basic components of an effective compliance program for a small physician practice that are based from the _______________?
Federal Sentencing Guidelines
A billing company's written policies and procedures should reflect current ________________
Federal and state statutes
Tim is the CO for a billing company. The CEO wants to know besides policies & procedures what other item is important for third parties to integrate into their compliance program. What would Tim's response be?
Federal and state statutes, regulations and health insurance guidelines
What law(s) does not require that nursing facilities conduct state or Federal FBI Bureau of Investigation criminal background checks?
Federal law
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:
Federal regulations
Which type of fraud covers any criminal fraudulent activity that has been determined to have involved electronic communications of any kind?
Federal wire fraud (18 USC1343)
Which one of the following is NOT considered an engineering control?
Floor cleaning devices
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? Kim replies:
For 30 years past the time the employee resigns / is terminated.
Employees that are exposed to Blood Borne Pathogens must be offered the Hep B Vaccination:
For Free
The __________ usually requires that police officers have probable cause before they search a person's home, their clothing, car, or other property. This also relates to businesses and the search of their premises.
Fourth Amendment
What is FPS?
Fraud Prevention System
What is the maximum amount of money an employer can charge for personal protective equipment?
Free of charge
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established what comprehensive program to combat fraud committed against all health plans, both public and private?
HCFAC (Health Care Fraud and Abuse Control)
CMS is a division of ________.
HHS
The OIG is a division of which agency?
HHS
What regulation protects the privacy of identifiable health information?
HIPAA
What does HITECH stand for?
Health Information Technology for Economic and Clinical Health
Having open and frequent communication with _____________ is a key to the fundamental success of a compliance program within a medical billing company?
Health care providers
What is the level 3 of the RAC claims appeal process?
Hearing by an Administrative Law Judge (ALJ)
The purpose of EMTALA is to prevent:
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.
Which of the following is not part of the annual OSHA employee training?
How to voice concerns about a HIPAA
What goes together with compliance issues?
Human Resources
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.
II, III, V-VII
Which of these statements is true?
IRS, DOL, PBGC all have separate penalty assessments
What agencies oversee ERISA?
IRS, PBGC, DOL
When is it acceptable to bill an office visit based on time?
If over half the visit is spent counseling the patient
When can patients instruct their provider not to share information about their treatment with their health plan?
If when scheduling an appointment, the patient indicates that he or she is paying cash for the visit and does not want his or her information to be given to the health plan
John is the new Compliance Officer for a small community medical practice of 10 providers. He wants to design a great compliance plan for the group. What does the OIG consider the most important aspect of a Compliance Program?
Implementation
What is the most important aspect of a Compliance Program?
Implementation
What is the most important aspect of a compliance program?
Implementation
What does the OIG consider the minimum requirements for a well-publicized guideline that includes disciplinary steps?
Including the disciplinary steps in the company's in-house training and procedure manuals
Which is true with regard to internet usage?
Inform employees that internet usage is monitored
If a patient presents to an emergency room the provider must not delay the screening process to ask about what?
Insurance
What authority have CMS contractors been given?
Interview providers and office personnel
Because of the changing nature of healthcare regulation, the Compliance Program
Is continually a work in progress
For potential criminal violations, a practice should have immediate discussions with a criminal attorney who
Is well versed in Healthcare Fraud and Abuse law
What is a OSHA 300 for used for?
It provides a total for job-related injuries for the year
What is a OSHA 300 form used for?
It provides a total for job-related injuries for the year
There are many benefits of having an effective compliance program. One such benefit is:
It shows that the practice is making a good faith effort to be compliant.
There are many benefits of having an effective compliance program. One such benefit is:
It shows the practice is making a good faith effort to be compliant.
How does a GFCI function?
It will shut off in the event of a ground fault.
ABC Provider Group and Apple Medical Group agree to pool their resources for the purpose of accomplishing a specific task. This is called _____________.
Joint ventures
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 groups also employs Nurse Practitioners whereas the other specialties only have MD's or DO's. How should Kelly address these special issues?
Kelly should give specialized training to coders and billers that code/bill for the Pediatricians and Family Practice that takes into account the Medicaid insurance and Nurse Practitioners because this is creating extra work for two out of the six specialties.
What is (are) considered a significant element(s) in fraud?
Knowingly and Intent
Which of the follow is not an example of Personal Protective Equipment (PPE)?
Lab Coat
Steve is the CPCO for Orange Labs. The CEO asked Steve if Laboratories should develop standards of conduct for employees?
Laboratories should develop standards of conduct
Which of these statements is NOT true with regard to limits of auditor record requests?
Large Group (16+ individuals): 30 medical records per 45 days per NPI
What does the acronym LEP stand for?
Limited English Proficiency
What is the jurisdiction limit of Medicaid Fraud Control Units (MFCUs)?
Limited to investigating Medicaid provider fraud
What usually happens next when settlement negotiations are unsuccessful?
Litigation
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?
Lockbox
The Medicare program has program manual instructions on overpayments. Generally, overpayments are returned to the____________?
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?
MFCU (Medicaid Fraud Control Units)
HR policies will need to __________________________________?
Make sense for the needs of the medical facility
Third party health care audits should be designed to address the company's ___________________.
Marketing services
A physician who fails to respond to an emergency situation when she is assigned as the on-call physician:
May be in violation of EMTALA, and may subject herself and the hospital to a penalty.
What is the most significant state program for healthcare?
Medicaid
What department has a statewide investigative program of Medicaid Fraud?
Medicaid Fraud Control Units
John is the Compliance Officer for ABC Medical Group. He is explaining to a group of providers the many types of acronyms that are associated with healthcare compliance. A provider asks John what the acronym MIP refers to. The answer is ____________?
Medicaid Integrity Program
Lim, a student that is studying for his CPCO researches to find out what third-party health care provider is becoming a vital part of the health care industry. What does he discover?
Medical Billing Companies
What third-party is in a unique position of fraud discovery?
Medical Billing Companies
What can result in imprisonment and penalties for providers and covered entities?
Medical fraud
The _________________________________ was signed into law which required 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 (MACs).
Medicare Modernization Act (MMA)
Which Act of 2003 gave momentum to the e-prescribing movement, and was put in place to reduce medication errors due to illegible physician handwriting, etc.?
Medicare Modernization Act (MMA)
Section 42 CFR contains federal regulations issued by CMS. The bulk of the federal regualtions in 42 CFR Part 4 cover the _____________________________________.
Medicare and Medicaid programs
What is a key concept of the Privacy Rule?
Minimum Necessary
The following is not a level of non-compliance:
Mistake in billing
he following is not a level of non-compliance:
Mistake in billing
Jackie is a coder/biller for ABC Provider Group. She often puts modifiers on various CPT codes so that they get paid, regardless of the meaning of the modifier. This is an example of:
Misuse of modifiers
__________________ 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.
Moderate and high complexity
After hiring, how often should providers check to make sure employees are NOT on the OIG List of Excluded Individuals?
Monthly
Compliance programs are.....
More dangerous if they are developed but not implemented.
What does NIOSH stad for?
National Institute for Occupational Safety and Health
Can an individual provide a verbal authorization to release PHI?
No
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?
No, EMTALA does not include physician practices
If I'm only doing blood draws, do I need a CLIA number?
No, a CLIA number is not required if the facility only collects specimens and performs no testing
Are Compliance Officers required to know all OSHA laws?
No, but the CO should know where to find the information
Judy is the Compliance Officer for Apple Medical Group. The providers of the group ask Judy to design a new Compliance Plan. Should Judy ask some other practices in town for a copy of their Compliance Plan? Do all Compliance Programs have to be the same regardless of the practice size or specialty? Why?
No, compliance programs need to be tailored to fit the unique needs of every organization or physician practice
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 the Clinics written policy, therefore, is in compliance.
No, laboratory may never ask a patient to sign a blank ABN
Are deceased patient records treated differently?
No, they are treated the same except providing to Funeral Directors
The Orange County Family Medicine Group employs 30 men and women. Are they required to offer FMLA to these employees?
No, they fall under the limit of 50 employees
Kim is the CPCO at Apple Hospital. A provider asks her if Medicare pays for all tests ordered by providers?
No, they need to determine if it's covered and medically necessary
The Release of Information (ROI) Specialist at Orange County Family Medicine group asks Larry, the Compliance Officer, if she is allowed to release all records at the facility as long as there is a signed patient release. Larry answers:
No- certain notes such as psychotherapy notes cannot be released.
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 object. Larry replies:
No. The provider is someone in authority and this is not acceptable.
As the new CPCO for XYZ Billing Company, Tim knows that a third-party health care company should start a compliance program:
Now, to be proactive
In addition to hospitals, what other type of facility did the OIG provide supplemental compliance program guidance for?
Nursing Facilities
The __________ is the entity where HIPAAis found.
OCR
The Office of Evaluation and Inspections is part of what Agency or Department?
OIG
What department monitors and recertifies MFCUs?
OIG
What can providers review that will help them understand the compliance requirements of a clinical lab?
OIG's Clinical Lab Guidance
Who is charged with the responsibility to assure safe and healthful working conditions?
OSHA
What federal agency is in charge of employee safety?
Occupational Safety and Health Administration (OSHA)
Which component of the OIG has a duty of conducting audits, which result in reducing waste, abuse, and mismanagement?
Office of Audit Services
Sue works for ABC Family Physicians. The providers at this office ask her research the department that helps to protect patients from unfair treatment or discrimination. What department or agency would that be?
Office of Civil Rights
Which office would a Compliance Officer contact if he or she had a question regarding discrimination in certain healthcare programs?
Office of Civil Rights (OCR)
The OlG Work Plan includes projects to be addressed during the fiscal year (and beyond) by the all of the following EXCEPT:
Office of HHS
Joan is the CO for ABC Provider Group. One of her providers asks her which Federal agency provides compliance program guidance to providers and covered entities? Joan tells the provider:
Office of Inspector General
Which department is the largest inspector general's office in the federal government?
Office of Inspector General
Medicaid Fraud Control Units (MFCUs) operate under the direction of __________.
Office of Inspector General (OIG)
What Federal department will consider self-reporting of misconduct as a mitigating factor?
Office of Inspector General (OIG)
Which government branch was created to fight waste, fraud and abuse in all federal health care programs especially Medicare, Medicaid?
Office of Inspector General (OIG)
Which OIG office conducts criminal, civil and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries?
Office of Investigations
The Compliance Officer is also responsible for the coordinating and/or screening of employees, agents, and independent contractors. Why is this important?
Organizations cannot do business with individuals who have been excluded from participating in federally funded healthcare plans
Providers must be enrolled in government programs to participate. They can do this either by paper versions or online through ______________.
PECOS (Provider Enrollment, Chain and Ownership System)
Tim, the Compliance Officer at Apple Internal Medicine Group, explains to the Apple Internal Group Board that the False Claims Act covers claims billed to Medicare:
Part A, B, C and D
Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as _________________.
Patient Abuse
When it is the intention of an organization to provide a safe environment to patients, it is good to design:
Patient Bill of Rights
Joan, Compliance Officer for XYZ Community Hospital gives a New Hire Orientation and explains to everyone that the following is the only information that is allowed to be given out to anyone that calls the hospital about the patient:
Patient Name, Location of Facility and General 1-word statement about the condition of the patient.
The Apple Internal Medicine Group is having a board meeting. Tim, the Compliance Officer explains that ________ is the most important concern for the Apple Internal Medicine Group Human Resource Department:
Patient Safety and Information Security
When a hospital sends a patient home, or transfers the patient, without providing care us called what?
Patient dumping
Which entity below could not bill for medically unnecessary services?
Patients
Which one of the following is considered a patient's right?
Patients can request an amendment to their medical record
MACs are responsible for administering the what for Medicare Services?
Payments
CPUP) The first large fraud case that involved a teaching hospital where Residents and Fellows worked was located in:
Pennsylvania
If the main entrance cannot be made handicap accessible, then ___________________.
People should be detoured to an alternative entrance
After an employee receives their initial training regarding the practice/organization Compliance Program what is the next step the compliance officer should take to protect the practice against potential noncompliance activity?
Perform a baseline assessment of the employee's competency scores to determine if additional training is required
Hannah is the Compliance Officer for Orange Hospital. She is explaining to her mother that Medicare Part B pays for what type of services?
Physician
Judy is the Compliance Officer for Apple Medical Group. The practice is a small group of providers. Judy wants to have an open door policy as suggested by the OIG, thus she will?
Post notices of up-to-date compliance information on the employee bulletin board
What does Medicare Part D cover?
Prescription Drugs
Tim is the HR Director at XYZ Family Provider Group. He wants to avoid liability for employing excluded entities or providers. He should check the OIG List of Excluded Individuals Entities on the OIG website how often?
Prior to hiring and monthly thereafter
What defines and limits the circumstances in which an individual's PHI may be used or disclosed by covered entities?
Privacy rule
What will show a third party that they have good faith towards remediation?
Prompt reporting
What is the routine cleaning guidelines for BP cuffs?
Provide disposable cuffs to all isolation patients
Which of the following is true per CMS website?
Providers billing fee-for-service are subjected to RAC audits.
What is the main purpose of the HIPAA Omnibus Rule?
Provides individuals new rights with regard to their health information
What type of office notes need to have special security?
Psychotherapy notes
Unless there is a conspiracy with a provider, MCFU cannot ______________________________>
Pursue recipient fraud
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?
QIO (Quality Improvement Organization)
What is an essential component for the lawful behavior and success of nursing facilities?
Quality of Care
What was established for all laboratory testing by Congress passing the Clinical Laboratory Improvement Amendments (CLIA) in 1988?
Quality standards
__________ detect and correct past improper payments so that CMS and carriers, fraud investigators, and ________ can implement actions that will prevent future improper payments.
RACs/MACs
Which law increases the severity of penalties for violations involving organized crime?
RICO Act
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 the color:
Red is the standard
What information should NOT be included in a Hazardous Waste Policy?
Regulated waste information
Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of the teaching physician, except for what?
Review of Systems (ROS) or past family or social history (PFSH)
What should not be ignored and may require necessary policy measures to prevent avoidable recurrence?
Risk areas
The aim of this program was to ensure that every child under the age of 18 had medical coverage.
SCHIP
The main tasks of __________ are to perform and/or provide 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.
SMRC (Supplemental Medical Review Contractor)
Federal regulations pertinent to billing companies include all except:
Safe Harbor Rules for Billing Companies
What OPPS rule requires hospitals to include on the same claim all OPPS services provided at the same hospital to the same patient, on the same day, unless certain conditions are met?
Same-day rule
A provider group also has a radiology clinic. The providers refer all mammograms to their own radiology clinic. This is an example of:
Self Referrals
The OIG's ______________ to Congress keeps the Secretary of the HHS and Congress currently informed about OIG's most significant findings, recommendations, and activates for specific six-month periods.
Semi-annual report
When physicians (or their staff) make billing mistakes and errors the most important thing to do is _________?
Send a refund
On what date do all covered entities need to be in compliance with HIPAA Omnibus Rules?
Sept 23 2013
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. The date was:
September 2013
Kim at Apple Hospital is explaining to her compliance committee about the components that are required by the OIG in order to have an effective Compliance Program. How many components does she tell them?
Seven
If physician recruitment arrangements are not properly structured it can result in
Significant fines and penalties.
The _______________________ addresses compliance concerns, such as compensation paid by laboratories to referring physicians and physician group practices for blood specimen collection, processing and packaging and for submitting patient data to registry or database.
Special Fraud Alerts
Which one of the following is NOT a component of PHI?
Spouse's name
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?
Stark
What is an example of using the process of complete elimination or destruction of all forms of microbial life?
Sterilization
Joan is an employee at XYZ Family Practice. She asks the Compliance Office what should you do when you find out one of your employees has been excluded from government programs?
Suspend the employee, request documentation, and investigate the matter.
What safeguard is defined as a measure to protect ePHI?
Technical safeguards
Routine waiver of co-pays would be considered a violation of which law?
The Anti-Kickback Statute
Which of the following is NOT true regarding Audit MIC?
The Audit MIC can only audit a Medicaid provider in an assigned state or zone
Which Act authorized the imposition of Civil Monetary Penalties against health care providers and entities that employ or enter into contracts with excluded individuals or entities to provide items or services to federal program beneficiaries?
The Balanced Budget Act (BBA)
Who is charged with the implementation of CLIA?
The Centers for Medicare and Medicaid Services (CMS)
The mission statement of the healthcare organization and a statement of why they are in business are also known as _________?
The Code of conduct
Whose responsibility is it to focus on the key risk areas through education and documented audit improvement?
The Compliance Officer
When the term Open Door Policy is used in reference to the Effective Communication, what is this referring to?
The Compliance Officer is accessible to all employees via many methods of communication
John is a student reviewing the information regarding compliance and wants to know "Who" or what agency is responsible for oversight of the Medicare and Medicaid Programs?
The U.S. Department of Health & Human Services (HHS)
What sets ZPIC audits apart from other Medicare audits?
The audits are targeted by potential Medicare fraud.
What are two requirements for an authorization to disclose PHI?
The authorization should have a right to revoke and should have an expiration
The OIG Compliance Program Guidance acknowledges patient care as:
The first priority of a physician practice
When drafting audit protocol in an internal investigation it should be carefully worded and tied back to the regulatory scope and applicability research. If an attorney does not draft the protocol, one should review it for language. Why?
The government or opposing party may obtain a copy
Violation of the Stark law occurs when:
The referring physician, or an immediate member of the referring physician's family, has a financial relationship with the entity receiving the referral
Improper advertising can get the physician in trouble with whom?
The state licensing board
When is an outside consultant and/or legal counsel necessary?
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.
Kim is the Director of Compliance for Apple Rural Health Center. One of the front office staff contacts her to ask what the term "minimum necessary" refers to. How would Kim answer?
This means covered entities should use or disclose the minimum amount of PHI needed for the intended purpose.
Tim works for XYZ Billing. His supervisor tells him to look up each CPT code that the provider sends to XYZ Billing to see if the code can be broken down into smaller codes and billed rather than one CPT code that is expensive. Tim tells the supervisor:
This would be considered unbundling and is illegal.
RACs can look back how many years from date of service?
Three
Laura is the CPCO for Angel Nursing home. She is explaining to the staff why is it important for nursing facilities to track patient outcomes. She states this is to:
To accomplish compliance
Why must an employer implement an Exposure Control Plan?
To ensure proper employee protection measure
A search warrant, State or federal (or both) allows the agents the right to what?
To enter and seize documents
When can PHI NOT be disclosed without a patient's consent?
To let your brother know his neighbor may have a contagious disease
John, Compliance Officer for ABC Internal Medicine Group, tells the Board of Directors that _________________ is the key factor in prevention of OSHA injuries and illnesses.
Training and Education
Pertinent components of an effective Compliance Program include _______________?
Training and educating employees
Anti-dumping statues, 42 U.S.C. 1395dd, require a hospital to do all of the following except?
Transfer to another hospital if emergency room is busy
PHI may be disclosed without the patient's authorization for ______________________.
Treatment, Payment and Operations
Kim, Compliance Officer for Apple Rural Health Center, explains to the staff that PHI can be used for the following:
Treatment, Payment, or Operations
If an employee is injured at work with a "sharp" that might be contaminated with another person's blood, the minimum information needed from the injured person?
Type and brand of device involved in the incident; location of incident; description of incident
USSC is important as it related to the Federal Sentencing Guidelines and thus related to the core elements of compliance. What does the USSC acronym stand for?
United States Sentencing Commission
Which one of the following is a requirement of MFCUs?
Units must employ attorneys
How often should Health Care Workers (HCW) receive TB testing in a medium risk facility?
Upon hire and every year
CLIA is funded by whom?
Users
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:
Waived tests and PPM procedures.
Dr. X is a very through provider. He always runs a full blood panel on each patient every year for their physical. This is an example of:
Waste
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. John replies:
We must follow the most stringent, therefore the State Guidelines
Which of the following is not a requirement for MSDS sheets?
What quantity the medical facility purchases yearly
When can an employer do a drug screen on employees?
When the employer has reasonable concerns of impairment
All expenses related to developing and implementing a compliance program are considered the cost of doing business and are tax deductible for the organization, except"
When the expenses are a result of the imposition of a penalty.
Which one of these situations will a provider not be able to deny a request for Release of Information Authorization?
When the patient signed more than 30 days prior
Under what circumstances can a relator NOT file a qui tam action?
When the qui tam action is based upon information that has been disclosed to the public; and when the government alrady is a party to a civil or administrative money proceeding
When would an employer need to complete an OSHA 300 form?
When there is a work-related contaminated needle stick or sharps injury
Why wouldn't a medical facility need an Ionizing Radiation Policy?
When they do not have an X-ray machine
When does an employee's declination of Hepatitis B expire?
Whenever the employee decides to get the vaccine
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 or his ____________ has a financial relationship with an entity:
Wife (only for family cousin is not included.)
Larry, the Compliance Officer for Orange County Family Medical Group, explains to the workers that the company will / will not pay for non-specialty safety toe protective footwear if Orange County Medical Group allows this to be worn off the job.
Will not pay
Payers expect all providers to refund monies that are overpayments. By law, this must occur...
Within 60 days of identification of overpayment
What is one of the main responsibilities of the CMS regional offices?
Work on quality initiatives
What type of insurance is required to cover an employee's work-related injury?
Workers' compensation
A Board member at Apple Rural Health Center wants to know if the ADA mandates an interpreter for patient appointments if needed?
Ye, if needed
Are there certain rules for PHI disclosure in cases of an emergency?
Yes, PHI can be released for emergency treatment
Can an employee transfer a chemical to another container?
Yes, as long as the secondary container label is used and meets regulatory requirements.
Texas orthopedics submits false Medicare claims through its electronic data interchange to its Medicare Administrative contractor based in Oklahoma. Can the orthopedic office be charged with federal wire fraud?
Yes, because false claims were submitted electronically across state lines.
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?
Yes, but the employer would be in violation of the Whistleblower Protection Law.
Can a patient restrict the disclosure of their PHI?
Yes, but the practice or medical organization doesn't have to abide by it
Can providers request an extension for providing records requested by an auditor if there is a problem meeting the deadline?
Yes, by calling the requestor and explaining the reason for delay
Can a billing company offer marketing services to its clients?
Yes, even if remuneration is involved
Is it acceptable for practices to call and remind patients of their appointments?
Yes, if it is stated in the Notice of Privacy Practices
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. John states:
Yes, if there is a subpoena
Tim at XYZ Billing wants to know if a billing company's Compliance Officer should work with the provider offices?
Yes, the OIG recommends this action
Does a provider who is only performing waived tests need a CLIA number?
Yes, the law requires that no matter what type of testing is performed, a CLIA number is required
Can the government take back money from a nursing facility for failure of patient care?
Yes, there is a direct link to quality of care and billing for services
Did the HIPAA Omnibus Rule affect Business Associates?
Yes, they are more accountable for their client's PHI
Can a patient restrict a provider from disclosing his or her PHI to family members when in the hospital?
Yes, they can restrict who knows about their condition
An emergency doctor at XYZ Community Hospital asks the Compliance Officer - Joan - if he is allowed to treat a patient that comes in to the ER but is alone and has dementia. He needs to release the PHI to the pharmacy for medicine. Joan replies:
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
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?
Yes. Mrs. Smith can request an amendment, however it is up to Dr. Jones if he will grant it and make the change.
What description below best describes ZPICs?
ZPICs are private companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments.
Joan, as an employee of a healthcare organization, has _________to report erroneous conduct, without repercussions, so that it may be corrected immediately.
a duty
According to Inspector General Daniel Levinson, what can help reduce enforcement on a provider from a CIA to a CCA?
a robust and effective compliance program
Kathy is thinking about specializing in healthcare compliance. Which entities below must have a OIG compliance plan?
a. Laboratories, DME and Ambulance providers b. Home Health, Hospice and Nursing Homes c. Small and Large Provider Groups, Hospitals and Nursing Homes
Joan is the Compliance Officer for XYZ Community Hospital. A Medicare patient recently saw one of the providers and paid cash for the services. They asked that the information NOT be sent to Medicare. The provider said that he:
agreed not to send the information to Medicare since the patient had paid cash for the services.
The 250-yard zone rule does not apply to:
all hospital-owned physician practices
A hospital may satisfy their on-call coverage obligations by __________per HHS.
approved community call/regional call program
Tim at XYZ wants to conduct a baseline audit to help determine?
areas of the billing department that might be in compliance
The OIG guidance recommends new employees should be trained in standards and procedures_____________ as part of their orientation to the practice.
as soon as possible
Billing Companies should never use _________________ coding.
assumption
Kathy, the Compliance Officer at a small provider office, is notified that a non-English speaking patient will be arriving today. A LEP person/patient who needs an interpreter to translate to and from the person's primary language must be provided.
at no cost to the patient or insurance carrier
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 are not. This assessment is called what?
baseline
Judy, 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 type of audit is this?
baseline
If the government intervenes in the qui tam action, the relator is entitled to receive how much of the amount recovered by the government through the qui tam action?
between 25 and 30 percent
What is not a definition of an occupational exposure?
bruised skin
Some of the largest breaches reported to HHS have involved ___________.
business associates
Cylinders containing flammable gases such as hydrogen or acetylene must NOT be stored __________________________________.
by aisles or walkways
Primary safety concerns in the medical setting include bloodborne pathogens, radiation, bio-hazardous waste, and _______.
chemicals
Which of the following designated individuals should be the best choice to review claims in a prospective audit before they are submitted to the payer?
compliance officer
The HITECH Act revisions significantly increased the penalty amounts the Secretary may impose for violations of the HIPAA rules and encourage prompt _____________?
corrective action
Audit MICs can audit a Medicaid provider throughout the ______________.
country
Kim, Compliance Officer for ABC Provider Group, created a compliance plan and policy a 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. 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
Alerts for Physician's Office labs from Medicare on expired certificate will cause you Medicare carrier to
deny claims
If the practice uses an outsourced compliance officer the OIG recommends_____?
designating a liaison from the practice to communicate with the outside compliance officer; and that the practice has a business service agreement with the outside compliance officer
Participants in the Federal healthcare programs have an obligation to take measures, such as instituting a compliance program, to _________________?
detects and prevent fraudulent, abusive and wasteful activities
The Compliance Officer's main two responsibilities are to ____________the practice/organization's compliance program.
develops and then implement
A lab's requisition form should include the following:
diagnosis information for all test ordered
The major sections of the Social Security Act address ________, ________, and ________
disability, unemployment, and social security
The biller at XYZ Community Hospital wants to win the award every month for posting the most insurance checks. Instead of giving the claims 30-60 days to clear, she bills them again at the end of the month. This is an example of?
double billing
Joan, as an employee of a healthcare organization, has _________to report erroneous conduct, without repercussions, so that it may be corrected immediately
duty
One of the most important elements of an effective compliance program is to have a compliance officer or committee who is__________.
empowered
Any laboratory performing testing on specimens derived from a human being for purposes of providing diagnosis, prevention, treatment, or assessment of health, regardless of whether they participate in Medicare, must:
enroll In the CLIA program
The Patient Protection and Affordable Care Act of 2010 (ACA) requires that all providers adopt a compliance plan as a condition of ______ with Medicare, Medicaid, and CHIP?
enrollment
Physicians who negligently violate EMTALA are subject to civil monetary penalties and for repeated or gross and flagrant violations risk__________?
exclusion from Medicare
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?
fair market value
The hospital that John works for was just issued a CIA. What is the typical
five years
If an employee, provider or anyone that deals with Federal or State healthcare dollars has intent to receive payment for services not legitimately rendered this is considered ______________?
fraud
The HCFAC program is designed to coordinate federal, state, and local law enforcement activities with respect to healthcare _________________________.
fraud and abuse
As specified in the Code of Conduct, no employee or agent of the practice/organization may have a relationship if they have a criminal conviction related to health care or __________________________?
have been excluded from participating in federally funded healthcare plans.
An effective compliance program can ____________________.
help create financial success, customer loyalty, community support, and employee satisfaction
In relation to reporting an incident, under what instances might a person's confidentiality not be maintained?
if/when governmental authorities become involved
Larry is a Non Physician Provider (PA) and he is explaining that the services he delivers to patients must be delivered under the provider's direct supervision and the provider must be ____________ if he is going to bill Incident To.
in the same office suite
The OIG Work Plan considers a number of factors, EXCEPT:
inconvenience to the healthcare industry
A person studying for the CPCO should review compliance guidance for __________________________________________________________?
individual and small group physician practices, third party billing companies, clinical laboratories, and hospitals
It is important to educate employees of 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?
intra-office or USPS mail
Joan at ABC Provider Group has a provider (Dr. X) that is going on vacation. The group has hired another provider that will start this week. The new provider is from a different state and will need to apply for a license to practice medicine. Dr. X says that it is alright to let the new provider use his billing and license numbers while he is on vacation. This is an example of:
knowing misuse of provider identification numbers
The compliance program will flounder if employees of the organization are not aware of _________?
laws and regulations that pertain to their specific job descriptions
MACs are responsible for administering the payment of Medicare services. Providers and suppliers submit their claims to the MAC and are paid based on _________________.
locally influenced fee schedules
Carol, Compliance Officer for XYZ Internal Medial Group needs to hire some physicians when a few of the owner physicians want to take a long vacation. The short term physicians hired are called____________________.
locum tenens
ZPICs target both the _____________ of a claim and ___________ errors.
medical necessity, coding
Compliance programs are
more dangerous if they are developed but not implemented.
What foreign languages does OSHA mandate the OSHA poster be posted with at each medical facility?
no requirement
Incident-to services are defined as those services that are furnished incident to physician professional services in the physician's office (whether located in a separate office suite or within an institution) or in a patient's home. Incident-to services are provided by a ____________.
non physician provider
What policy is written to encourage communication?
non retaliation policy
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 ______.
not a resident
You cannot protect certain facts from disclosure simply by communicating them to your lawyer. If information may be gathered from another source besides the privileged communication, then the underlying information itself is ______________________.
not privileged
How long does the Privacy Rule state that a practice or covered entity need to retain medical records?
not stated
During an internal investigation, creating an audit report for negotiation is important. Overpayments (as well as underpayments) should be included as_________.
offsets
To meet EMTALA guidelines, a physician must attest (in writing) that the medical benefits expected at the receiving facility ____________________. 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 his refusal to consent to a physician-recommended transfer should also be documented
outweighs the risk of transfer
Penalties and exclusion from the Medicare program may be imposed on a _________________ who is convicted of repeated or "gross and flagrant" violations of EMTALA.
physician
A high-level statement or plan that embraces an organization's general beliefs, goals, objectives and acceptable procedure for a specified subject area is a _______________?
policy
What are not part of Exit Route requirements for a medical facility?
posting evacuation routes on the company web site.
Once Hannah, Orange Hospital Compliance Officer identifies the risk levels, what is the next step a compliance officer should take?
prioritize which risks will be addressed
What is more important to have in place for enforcing and disciplining individuals who violate the practice's compliance or other practice standards?
procedures
States may also offer CIAs to providers with a history of________ as an alternative to exclusion from the Medicaid program.
program integrity issues
Several requirements must me met before transferring an unstable patient, per EMTALA rules. The consent of the __________________________________ must be obtained.
receiving hospital
Private or government investigations usually start with a request for __________.
records
Circumnavigation schemes can occur when a physician or other entity enters into an arrangement that the entity /physician knows that ____________will occur.
referrals
Under EMTALA, all Medicare participating hospitals are required to provide at least a medical screening exam to a patient who comes to the emergency department ...
regardless of the patient's insurance or ability to pay.
In order for a compliance program to be effective, it will need to be ___________________________________.
regularly reviewed and updated
person who exposes misconduct, alleged dishonest or illegal activity occurring in an organization is called a______________?
relator
The Signatory page includes the signatures of the provider representatives (counsel and the Compliance Officer and/or president), as well as the _______.
representative from the OIG
Incident rules can be complicated and present additional risks to a practice/organization. If a provider is available only via pager or telephone, incident-to billing the ____________________?
requirements are not met
What employees DO NOT fall under Category II?
security officers, nursing, physicians, respiratory therapists, rehabilitation, lab, etc.
How many elements are required to have a successful compliance program?
seven
When Judy, Compliance Officer for the Apple Medical Group, designs the compliance plan she will follow what OIG has described in the Federal Register. How many basic components of an effective compliance program is listed for a small physician practice?
seven
What employees do not fall under Category I?
social workers
States and territories must adhere to the federal CLIA. If the state guidelines are more stringent, then ____________ must be followed.
state guidelines
When Kim from ABC Provider Group is conducting a risk assessment, one of the most important and key sources of information that Kim as the Compliance Officer should utilize is_____________.
the Office of Inspector General's Annual Work Plan
When Kim from ABC Provider Group is conducting a risk assessment, one of the most important and key sources of information that a Kim as the Compliance Officer should utilize is____________
the Office of Inspector General's Annual Work Plan
John is the Compliance Officer for ABC Internal Medicine Group. The Director of Operations thinks that it would be a good practice exercise to have an emergency exit route that is moved every month so that employees are up to date on the exit plans. John explains that_________
the exit route must be permanent
Failure to respond quickly to suspected or alleged instances of non-compliance threatens the organization's reputation as trustworthy, law-abiding, and ______________?
the organization's ability to participate with federally funded healthcare plans and/or third party payers.
What might one reason be for Medicare not to pay for a service provided to a Medicare beneficiary?
the service was not covered
OIG negotiates CIAs with healthcare providers and other entities as part of the settlement of federal healthcare program investigations arising under a variety of Civil False Claims statutes. Providers or entities agree to the obligations and, in exchange, the OIG agrees not to seek _______________________________________________________.
their exclusion from participation in Medicare, Medicaid, or other federal healthcare programs.
During the monthly new hire training, Sarah , the Compliance Officer for Apple Hospital, explains that as an element of a billing and reimbursement compliance program is essential. Employees must be aware of the compliance issues and the applicable laws and regulations especially those that pertain to what?
their specific job descriptions
What rights do patients have when paying cash?
they can restrict the use of their PHI
The CEO at XYZ Community Hospital discusses with Joan, the Compliance Officer, that the exit door from the hospital is allowing employees to steal during non-peak hours. He would like the door locked between 2 - 4 am. Joan explains that________________:
this cannot happen because the exit door must always be kept unlocked
Dr. Smith asks you, the Compliance Officer, what is the typical term of a CCA?
three years
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
Sarah, Compliance Officer for Apple Hospital explains to the providers the meaning of ___________________, which is the practice of a physician billing for multiple components of a service that must be included in a single fee.
unbundling
Urine dipsticks and finger-stick blood tests performed in a physician's office subject the office to CLIA regulations. These are called _______________________.
waived tests
All expenses related to developing and implementing a compliance program are considered the cost of doing business and are tax deductible for the organization, except:
when the expenses are a result of the imposition of a penalty.
Tim is a patient at ABC Internal Medicine Group. Tim is HIV positive. John, the Compliance Officer explains to Tim that the medical group
will have to release information to the State Health Department - that is the law.
How soon are practices or medical organizations required to process patient's record request when the information is maintained or accessible on-site?
within 30 days
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.
work plan
Mr. and Mrs. Jones are divorced. They have a child named Jane. Mr. Jones Does Not pay child support. Only Mrs. Jones takes care of Jane. Does Mr. Jones have any rights to Jane's medical records?
yes, hes the father
