CPCO prep

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

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

What would require a high-level disinfection? Disposable vaginal speculum Vacutainer tube Endoscope Needles used for blood draws

Endoscope Items requiring high-level disinfection are objects that come in contact with mucous membranes or skin that is non-intact such as respiratory therapy and anesthesia equipment and endoscopes.

Which of the following is considered the primary means of minimizing employee exposure? Policies and procedures Engineering controls Personal protective equipment Drills

Engineering controls Engineering controls are the primary means of eliminating or minimizing employee exposure, and include training and the use of safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes.

What is a key concept of the Privacy Rule? Training Minimum Necessary Communication Notice of Privacy Practices

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

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

Monthly To avoid liability for employing excluded entities, providers should check the OIG List of Excluded Individuals Entities on the OIG website, as well as any state exclusion website. Providers can purchase services that check exclusion status in real time. Prior to hiring a permanent or contract employee, the provider should check the exclusion list, and do so monthly thereafter, so that there is little chance of submitting claims for an excluded person.

When there is notice of an investigation, employees must know that it is against policy to __________. Answers: Alter, destroy or remove any documentation from a patient's medical record Discuss the matter with other employees Ask for identification Speak with investigators

Selected Answer: Correct Alter, destroy or remove any documentation from a patient's medical record Response Feedback: When there is notice of an investigation, communicate to employees that it is against policy to alter, destroy or remove any documentation from a patient's medical record. It is best practice to have this typed out and signed by all employees, and kept in a file for future reference.

Which entity below could not bill for medically unnecessary services? Hospitals Physicians Ancillary providers Patients

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

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

Privacy Rule The Privacy Rule defines and limits the circumstances in which an individual's PHI may be used or disclosed by "covered entities" — all providers, health plans, and others who have access to PHI.

In order for a compliance program to be effective, it will need to be _________. Reviewed daily for any compliance updates Regularly reviewed and updated Reviewed by healthcare lawyers Reviewed weekly for any compliance updates

Regularly reviewed and updated Simply implementing a compliance program is not enough. It will need to be reviewed and updated on a regular basis.

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

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

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

Selected Answer: A zero tolerance policy for harassment Response Feedback: Having a zero tolerance policy on harassment protects a company from liability.

Routine waiver of Medicare deductibles or copayments is a violation of which statute? Answers: Anti-Kickback Civil Monetary Penalties False Claims Act Stark II

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

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

Selected Answer: Correct Ask the patient if the dog is a service animal and, if the patient states yes, allow the animal on the premises. Response Feedback: There should be a clear policy about service animals to help ensure staff is aware of its obligation to allow access to patients with service animals. Additional information can be located at: http://www.ada.gov/service_animals_2010.htm.

OIG integrity agreements have been a catalyst for change in _______________? Answers: a. fines b. training c. policies d. corporate culture

Selected Answer: d. corporate culture Response Feedback: Effective compliance systems are key to strengthening the integrity of the health care system. OIG integrity agreements have been a catalyst for change in corporate culture, and can result in the development of comprehensive internal control systems. Their communications with providers during the course of compliance monitoring efforts have also enhanced compliance within their organizations.

Comprehensive Error Rate Testing Program (CERT) started in what year? Answers: 2000 2001 2003 2010

Selected Answer: Correct 2001 Response Feedback: The transition started in 2001, with the first overpayment report in 2003.

The typical duration of a Corporate Integrity Agreement (CIA) is? Answers: 1-2 years 6 months 3-5 years The agreement is permanent and does not expire.

Selected Answer: Correct 3-5 years Response Feedback: A comprehensive CIA typically lasts 3-5 years.

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

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

How many regions are part of the Medicaid Fraud Control Unit? Answers: 3 6 9 12

Selected Answer: Correct 6 Response Feedback: Regions are located in: Northeastern Region; Eastern Region; Southern Region; Midwestern Region; Central Region; and Western Region.

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

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

A billing company's written policies and procedures should reflect current ___________________. Federal statutes Federal and state statutes Local and federal statutes State statutes

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

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

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

What is the maximum amount of money an employer can charge for personal protective equipment? $5 per pay $10 per pay Free of charge for the first year of employment Free of charge

Free of charge Personal Protective Equipment (PPE) will need to be provided to your employees at no expense to them.

The OIG is a division of which agency? CMS Medicaid HHS NGS

HHS The Office of Inspector General (OIG) operates within the U.S. Department of Health & Human Services (HHS) to identify vulnerabilities in the healthcare system, to offer compliance guidance to healthcare facilities and professionals, and to promote accountability and enforce regulation.

Per this section, what can be an effective support system of the desired organizational culture? Selected Answer: Correct Answers: Auditing and monitoring HR policies and procedures Management Security personnel

HR policies and procedures The establishment of HR policies can be an effective support system of the desired organizational culture.

An effective compliance program can _________________________. 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.

When can patients instruct their provider not to share information about their treatment with their health plan? Never, patients have to disclose all information to their health plan. Only if the patient tells the secretary when scheduling an appointment that his or her information should not be given to his or her health plan. I 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. Never, because the health plan has a contract with the provider.

I 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. The patient has to make cash arrangements when scheduling appointment and state that visit information is not to be shared with the health plan.

What is the most important aspect of a Compliance Program? Training Implementation Development Discipline

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

Because of the changing nature of healthcare regulation, the Compliance Program Should only be updated annually to make sure you capture all the changed regulations Should be updated biannually Makes it is necessary to hire a consultant to review the program for accuracy Is continually a work in progress.

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

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. It provides a means to cover errors until they can be fixed. It allows employees to retaliate against their employer when they believe they have been treated unfairly. It provides a basis for the OIG to create a CIA if a problem is identified.

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

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

It will shut off in the event of a ground fault. GFCI is a fast-acting circuit breaker designed to shut off electric power in the event of a ground fault within as little as 1/40 of a second.

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 $10,000-$21,000, plus the assessment of not more than three times the amount claimed for damages $5,500-$11,000, plus the assessment of not more than three times the amount claimed for damages There is no maximum penalty.

$10,781-$21,563, plus the assessment of not more than three times the amount claimed for damages In 2016, the Civil Monetary Penalties Inflation Adjustment increased the penalty to $10,781 - $21,563 (effective for false claims made after November 2, 2015). Penalties for violation of this law are calculated through the CMP law (explained above) and range between $10,781-$21,563 for each false claim submitted, plus three times the amount of damages (the amount of the claim).

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? $20,000, and an assessment of three times the amount of the kickback $50,000, and an assessment of three times the amount of the kickback $75,000, and an assessment of three times the amount of the kickback $100,000, and an assessment of three times the amount of the kickback

$50,000, and an assessment of three times the amount of the kickback The government may levy a civil fine of up to $50,000 for each violation of the anti-kickback statute, and an assessment of three times the amount of the kickback.

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

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

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

15-25% If the government intervenes in the qui tam action, the relator is entitled to receive between 15 to 25 percent of the amount recovered by the government through the qui tam action. If the government declines to intervene in the action, the relator's share is increased to 25 to 30 percent.

What year did OSHA publish the Bloodborne Pathogens Standard? 1991 1996 2001 2002

1991 OSHA published the Occupational Exposure to Bloodborne Pathogens standard in 1991 because of a significant health risk associated with exposure to viruses and other micro-organisms.

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

40% Data indicates that CLIA has helped to improve the quality of testing in the United States. The total number of quality deficiencies a laboratory experiences has decreased approximately 40 percent from the first laboratory survey to their second.

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

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

How many percutaneous injuries involving contaminated sharps occur annually? 400,000 550,000 600,000 625,000

600,000 The Centers for Disease Control and Prevention (CDC) estimates that healthcare workers sustain nearly 600,000 percutaneous injuries annually involving contaminated sharps.

Fraud waste and abuse are all areas that must be controlled when providing services to beneficiaries. Fraudulent billing is: A series of errors. Only an issue if the erroneous billing is identified and not resolved. Only occurs when refunds are not issued in a timely manner. A willful act.

A willful act. Fraudulent billing is willful, and is undertaken with the intent to receive payment for services not legitimately rendered.

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

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

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

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

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) Deficit Reduction Act (DEFRA) False Claims Act (FCA) Fraud Enforcement and Recovery Act (FERA)

Medicare Modernization Act (MMA) The Medicare Modernization Act (MMA) of 2003 was put in place to reduce medication errors due to illegible physician handwriting, etc., and gave momentum to the e-prescribing movement.

What are the requirements for containers used to store waste? a. Container cannot be located in stair well b. Container must be color-coded c. Container cannot be in patient care areas d. Container must be red

b. Container must be color-coded Containers used to store waste must be suitable and closable. If there is a leak, the container must be placed in a second container. Sharps containers must be puncture resistant. Containers must be labeled or color-coded so employees know of hazards, and must be closed before removal to prevent spillage.

The Compliance Officer at Apple Internal Medicine Group explains to the Board that there is a difference between the FCA Civil and Criminal law. The difference is: a. Civil and CMP work together. Criminal FCA does not work with CMP. b. Criminal states that proof must be beyond a reasonable doubt. c. Civil involves fines as a penalty. Criminal involves jail time only. d. Coding mistakes are fined under Civil but not Criminal.

b. Criminal states that proof must be beyond a reasonable doubt. Answer is b. The FCA does not encompass mistakes, errors, or negligence. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.

Judy at Apple Medical Group wants to know why Hot Line allegations should be tracked? a. Look for groups of employees who complain b. Establish patterns or trends that need to be followed c. In order to find out who is making the call d. As a way to catch 100% of false claims

b. Establish patterns or trends that need to be followed All hotline concerns should be investigated and the outcome recorded in order to look for patters or trends of non-compliance that would help to establish the types of correction action steps will be required.

Which of the following is not part of the annual OSHA employee training? a. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials b. How to voice concerns about a HIPAA c. Information on the post-exposure evaluation and follow up that the employer is required to provide for the employee following an exposure incident d. An explanation of the signs and labels and/or color coding

b. How to voice concerns about a HIPAA HIPAA and OSHA training need to be separated. Employees should receive annual refreshers on both areas of importance.

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

b. Whenever the employee decides to get the vaccine At any time after signing the Hepatitis B declination form an employee change their mind and can then receive the vaccination series at no charge to them.

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. a. Will pay b. Will not pay c. Will not pay but will replace the laces for free. d. Will pay for part of the footwear.

b. Will not pay Will not pay. The employer is not required to pay for non-specialty safety-toe protective footwear (including steel-toe shoes or steel-toe boots) and non-specialty prescription safety eyewear, provided that the employer permits such items to be worn off the job site.

Can a patient restrict the disclosure of their PHI? a. No b. Yes, but the practice or medical organization doesn't have to abide by it c. Yes, and the practice or medical organization will need to abide by it d. Yes, but not for treatment, payment or operations

b. Yes, but the practice or medical organization doesn't have to abide by it Patients have the right to request restrictions of our uses and disclosures of their PHI for treatment, payment, or health care operations. However, the provider does not have to abide by their request.

Jill is the Compliance Officer for a small provider group. Jill wants to send all lab referrals to the lab that her physician group own. Is this considered fraud? a. No, it is considered abuse. b. Yes, it is considered fraud. c. No, it is considered waste. d. Yes, only because lab services owned by providers is a special category so therefore it is fraud.

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

Did the HIPAA Omnibus Rule affect Business Associates? a. Yes, they can no longer get PHI without patient consent b. Yes, they are more accountable for their client's PHI c. No, Business Associates are excluded from PHI d. No, everything stayed the same

b. Yes, they are more accountable for their client's PHI The HIPAA Omnibus Rule makes Business Associates more accountable for PHI. If they have a HIPAA breach, they are now required to report it not the client.

Can a patient restrict a provider from disclosing his or her PHI to family members when in the hospital? a. No, if family comes to see how patient is feeling nurses will provide PHI b. Yes, they can restrict who knows about their condition c. No, providers have a right to talk to patient's family awaiting results d. Yes, only if they provide it in writing 30 days prior to hospitalization

b. Yes, they can restrict who knows about their condition Patients can also request that providers not disclose PHI to notify family members or others about the individual's general condition, location, or death.

Tim is a patient at ABC Internal Medicine Group. Tim is HIV positive. John, the Compliance Officer explains to Tim that the medical group: a.will keep all information confidential on Tim. b.will need to release the information because that is the state's law to require that information. c.will only release information when they see a need to. d.will only release information if Tim has signed a release form.

b.will need to release the information because that is the state's law to require that information. If patient lives in a state that require providers to report information when a patient has certain communicable diseases, even if the patient doesn't want the information reported.

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

c. 2001 Congress passed the Needle stick Safety and Prevention Act was published on Jan. 18, 2001 and became effective April 18, 2001.

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

c. 60 The qui tam complaint is initially sealed for 60 days.

OSHA requires that employers report to OSHA all work related fatalities within _________ a. 24 hours b. 12 hours c. 8 hours d. 4 hours

c. 8 hours 8 hours. Reporting to the nearest OSHA office all work-related fatalities within 8 hours, and all work-related inpatient hospitalizations, all amputations and all losses of an eye within 24 hours.

When physicians (or their staff) make billing mistakes and errors the most important thing to do is _________? a. Resubmit the claim again b. Apply a credit to the patient account c. Send a refund d. Document the error

c. Send a refund When physicians (or their staff) make billing mistakes and errors—which can happen given the number of regulations—simply refunding payments will often settle the account.

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

c. Spouse's name A spouse's name is not counted as PHI according to the HHS website.

Physicians sometimes own other health-related businesses, such as physical therapy facilities, DME or home health companies, diagnostic imaging centers, or laboratories. Because these businesses provide designated health services, what may be triggered? a. Qui Tam b. Anti-kickback c. Stark d. FCA

c. Stark Physicians sometimes own other health-related businesses, such as physical therapy facilities, DME or home health companies, diagnostic imaging centers, or laboratories. Because these businesses provide designated health services, Stark is triggered.

Who is responsible for providing analysis, research, and technical assistance and conducts laboratory quality improvement for CLIA? a. Centers for Medicare and Medicaid Services (CMS) b. World Health Organization (WHO) c. The Centers for Disease Control and Prevention (CDC) d. The American Medical Association (AMA)

c. The Centers for Disease Control and Prevention (CDC) The Centers for Disease Control and Prevention (CDC) is responsible for providing analysis, research, and technical assistance and conducts laboratory quality improvement for CLIA.

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

Selected Answer: Correcta. That the attorney is not the employee's attorney. Response Feedback: If your attorney does the interview, the employee needs to know the attorney is not the employee's attorney. The employee can be asked to keep the interview confidential. Short and well-drafted interview memos should be created—again, with the expectation that they could be viewed by opposing counsel.

Whose responsibility is it to focus on the key risk areas through education and documented audit improvement? Answers: a. The Compliance Officer b. The front desk staff c. The Nursing Supervisor d. The providers

Selected Answer: Correcta. The Compliance Officer Response Feedback: As a compliance officer you need to focus on the key risk areas through education and documented audit improvement. Policies that are hard to understand and follow cause significant harm in investigations. Taking the proactive instead of reactive approach saves time and resources in the end.

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

Selected Answer: Correcta. To take preventative actions of musculoskeletal disorders Response Feedback: Companies may want to evaluate the ergonomics in the office to identify situations that could result in musculoskeletal disorders.

Should American taxpayers be concerned about Medicaid fraud? Answers: a. Yes, it cost taxpayers hundreds of millions of dollars a year b. Yes, it cost taxpayers thousands of dollars a year c. No, the government has plenty of auditors d. No, the Medicaid Fraud Units will take care of the issue

Selected Answer: Correcta. Yes, it cost taxpayers hundreds of millions of dollars a year Response Feedback: Medicaid provider fraud costs American taxpayers hundreds of millions of dollars annually and hinders the very integrity of the Medicaid program.

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

Selected Answer: Correcta. Yes, they should still address leaves of absence requests Response Feedback: If the Organization is not required to provide a leave of absence through the Family and Medical Leave Act, there should still be a policy that addresses leaves of absence.

The HITECH Act revisions significantly increased the penalty amounts the Secretary may impose for violations of the HIPAA rules and encourage prompt _____________? Answers: a. corrective action b. release of records c. repayment d. pay rules

Selected Answer: Correcta. corrective action Response Feedback: These HITECH Act revisions significantly increased the penalty amounts the Secretary may impose for violations of the HIPAA rules and encourage prompt corrective action.

John, Compliance Officer for ABC Medical Group told the Board that when conducting a risk assessment, that coding and billing are considered to be what level of risk to an organization? Answers: a. high b. critical c. low d. moderate

Selected Answer: Correcta. high Response Feedback: Coding and billing are considered high risk areas that should be closely monitored to assure compliance with regulations and guidelines.

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? a. U.S Attorney's Office b. Office of Civil Rights c. The U.S. Department of Health & Human Services (HHS) d. OIG

c. The U.S. Department of Health & Human Services (HHS) The U.S. Department of Health & Human Services (HHS) oversees Medicare, Medicaid, public health, medical research, food and drug safety, welfare, child and family services, disease prevention, Indian health, and mental health services; and, it exercises leadership in public health emergency preparedness and combating bioterrorism.

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

c. The release or transfer of information to an outside entity The Health Insurance Portability and Accountability Act of 1996 (HIPAA) defines disclosure as "the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information."

Why do we need privacy rules? a. To protect employees b. To protect physicians c. To protect PHI d. To protect mid-level providers

c. To protect PHI Privacy and security rules are designed to protect patient medical information.

PHI may be disclosed without the patient's authorization for ____________. a. Treatment, Payment & Economics b. Treatment, Payment & Emergencies c. Treatment, Payment & Operations d. Treatment, Payment & Education

c. Treatment, Payment & Operations Ready access to treatment and efficient payment for health care, both of which require use and disclosure of protected health information, are essential to the effective operation of the health care system. In addition, certain health care operations—such as administrative, financial, legal, and quality improvement activities—conducted by or for health care providers and health plans, are essential to support treatment and payment.

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_______. Answers: a. locum tenens b. qui tam c. part time employees d. temporary employees

Selected Answer: Correcta. locum tenens Response Feedback: Locum tenens (Latin for "place holder") is when a physician contracts with a substitute physician to take over their professional practices when he or she is absent for reasons such as illness, pregnancy, vacation, or continuing medical education. In this situation, the regular physician bills and receives payment for the substitute physician's services as though he or she performed them

John, Compliance Officer for ABC Internal Medicine Group, explains to the providers that the accessible route into the building must be at least _______ Answers: a. 6 feet wide b. 3 feet wide c. 5 feet wide d. 4 feet wide

Selected Answer: Correctb. 3 feet wide Response Feedback: 3 feet wide. The path a person with a disability takes to enter and move through your business is called an "accessible route." This route must be at least three feet wide and remain accessible at all times; at no time should it be blocked by items such as vending or ice machines, newspaper dispensers, furniture, filing cabinets, display racks, or potted plants.

What percentage of compliance hotline calls pertain to human resources? Answers: a. 55% b. 50% c. 40% d. 25%

Selected Answer: Correctb. 50% Response Feedback: Recent surveys indicate that compliance hotlines receive approximately 50 percent human resource-related calls.

Who cannot be a violator of fraud? Answers: a. An employee of the provider b. Anyone can be a violator of fraud c. A provider d. A beneficiary

Selected Answer: Correctb. Anyone can be a violator of fraud Response Feedback: A violator may be a provider, a beneficiary, or an employee of a provider or some other business entity; basically anyone.

What must a Personnel Policy Manual adhere to? Answers: a. Title X b. Civil Rights Act c. Title VI d. Title V

Selected Answer: Correctb. Civil Rights Act Response Feedback: Personnel Policy Manuals need to adhere to the requirements of Title VII of the Civil Rights Act of 1964.

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

Selected Answer: Correctb. Corporate wrongdoing Response Feedback: The 2015 Yates Memo addresses corporate wrongdoing and holds administrators accountable as well as providers. More information can be found at: https://www.justice.gov/dag/file/769036/download. The Yates Memo could have a significant effect on healthcare companies and their executives for being held accountable for healthcare fraud.

What authority has CMS contractors been given? Answers: a. Access to all provider properties b. Interview providers and office personnel c. Interview patients about provider practices d. Withhold any reimbursements due to suspected fraud

Selected Answer: Correctb. Interview providers and office personnel Response Feedback: CMS contractors have the authority to request and review copies of provider records, interview providers and office personnel, and access provider facilities.

Remuneration for referrals is _______ and can also affect the quality of patient care by encouraging physicians to order services or supplies based on profit rather than the patients' best medical interests. Answers: a. legal if done properly with a contract b. discouraged c. illegal d. encouraged under the ACA

Selected Answer: Correctc. illegal Response Feedback: Remuneration for referrals is illegal because it can distort medical decision-making, cause overutilization of services or supplies, increase costs to federal healthcare programs, and result in unfair competition by shutting out competitors who are unwilling to pay for referrals. Remuneration for referrals can also affect the quality of patient care by encouraging physicians to order services or supplies based on profit rather than the patients' best medical interests.

Private or government investigations usually start with a request for __________? Answers: a. interviews b. refunds c. records d. policies

Selected Answer: Correctc. records Response Feedback: Private or government investigations usually start with a request for records. In some situations, the FBI or state Medicaid fraud unit could show up and take records pursuant to a search warrant.

Which screening exam does not require an order, in any setting, but frequently is still requested by the radiology center? Answers: a. MRI b. CT Scan c. Lab work d. Mammogram Response Feedback:

Selected Answer: Correctd. Mammogram Screening Mammography, in any setting, does not require an order, but should be performed before the radiologist orders other tests.

Who is responsible for administering and enforcing HIPAA's privacy, security and breach notification rules? Answers: a. Office of Medicaid b. Office of Attorney General c. WHO d. Office of Civil Rights

Selected Answer: Correctd. Office of Civil Rights Response Feedback: The Office of Civil Rights (OCR) is responsible for administering and enforcing HIPAA's privacy, security and breach notification rules.

Unless there is a conspiracy with a provider, MCFU cannot ___________. Answers: a. Place a provider on administrative leave of absence b. Arrest a provider c. Show up unannounced at a provider's practice d. Pursue recipient fraud

Selected Answer: Correctd. Pursue recipient fraud Response Feedback: Federal regulations prohibit the Units from pursuing recipient fraud, unless there is a conspiracy with a provider.

Joan, as an employee of a healthcare organization, has _________to report erroneous conduct, without repercussions, so that it may be corrected immediately a. 30 days b. an option c. a duty d. No obligation

c. a duty An effective compliance program sends an important message to employees that—although the practice recognizes mistakes will occur—employees have an affirmative duty to report erroneous conduct, without repercussions, so that it may be corrected immediately.

The CLIA of 1988, establishing quality standards for _____ laboratory testing to ensure accuracy. a. low risk labs b. high risk labs c. all d. waived

c. all All. Congress passed the CLIA in 1988, establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results, regardless of where the test was performed. A laboratory is defined as any facility that performs lab testing on specimens derived from humans for the purpose of providing information for the diagnosis, prevention, treatment of disease, or impairment or assessment of health.

Some joint ventures may violate the Medicare and Medicaid ______________? a. Enrollment process b. Claims processing manual c. anti-kickback statute d. FCA

c. anti-kickback statute The Office of Inspector General believes that some joint ventures may violate the Medicare and Medicaid anti-kickback statute.

A hospital may satisfy their on-call coverage obligations by __________per HHS a. having a nurse do the coverage b. not offering on call coverage c. approved community call/regional call program d. refusing treatment

c. approved community call/regional call program HHS has allowed hospital to satisfy their on-call coverage obligations by organizing an approved community call/regional call program.

The OIG guidance recommends new employees should be trained in standards and procedures_____________ as part of their orientation to the practice. a. 3 months after hiring the employee b. whenever convenient c. as soon as possible d. 30 days after hiring the employee

c. as soon as possible The OIG guidance recommends new employees should be trained in standards and procedures as soon as possible as part of their orientation to the practice. It is essential that all training should be documented in the employee's human resources file.

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. a. at a small fee to the patient b. for a small fee to the insurance carrier c. at no cost to the patient or insurance carrier d. none of the above

c. at no cost to the patient or insurance carrier 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.

Primary safety concerns in the medical setting include bloodborne pathogens, radiation, bio-hazardous waste, and _______. closed spaces chemicals patient care equipment non-patient care equipment

chemicals Key issues in a medical setting are bloodborne pathogens, radiation, chemicals, and bio-hazardous waste.

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? a. 15 years b. 20 years c. 12 years d. 10 years

d. 10 years Mail fraud (18 U.S.C. 1347) includes health care fraud, and covers anyone who knowingly and willfully executes, or attempts to execute, a scheme or artifice to (1) defraud any health care benefit program; or (2) to obtain by false or fraudulent pretenses any money or property owned by or under custody or control of any health care benefit program. Penalties include fines and imprisonment of up to 10 years.

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? a. 10 b. 30 c. 15 d. 60

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

The OIG has stated that an effective compliance plan can help create: a. customer loyalty b. community support c. financial success d. All of the above

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

Attorney-client privilege protects communications that you have with your attorney and ___________? Answers: Attorney-client work-product Reports and memos only Is a guarantee of non-disclosure of information Is required when you have a compliance program

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

RACs perform what type of review(s) Answers: Automated Prospective Complex Automated and complex

Selected Answer: Correct Automated and complex Response Feedback: There are two types of reviews: Automated (no medical record needed) and Complex (medical record required).

Audit MICs can audit a Medicaid provider throughout his or her__________. Answers: City County Country State

Selected Answer: Correct Country Response Feedback: An Audit MIC can audit a Medicaid provider throughout the country.

What type of software process identifies potential claim errors? Answers: Certified Error Rate Testing (CERT) Data mining Fishing MACs

Selected Answer: Correct Data mining Response Feedback: Sophisticated software uses "data mining" to identify potential claims errors.

LCDs and NCDs provide information for coverage limited to certain what? Answers: CPT® codes Diagnosis codes HCPCS Level II codes Inpatient codes

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

Which statement is true? Answers: a. All businesses should educate employees about ADA b. Employers with 50 or more employees are required to train about ADA c. ADA mandates an annual re-training of employees d. Only larger business are required to train employees about ADA

Selected Answer: Correcta. All businesses should educate employees about ADA Response Feedback: Businesses of all sizes should educate staff about ADA requirements.

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

Selected Answer: Correcta. Corrective action plan Response Feedback: It is the duty of the compliance officer to find those areas of non-compliance and formulate solutions to rectify the problems. Non-compliance issues identified through the periodic audits and through the established reporting system will need to be investigated. The compliance officer will initiate and/or coordinate corrective and preventive action for these areas.

What is FPS? Answers: a. Fraud Prevention System b. Fraud of Provider Services c. Fraudulent Provider System d. Fee for Provider Services

Selected Answer: Correcta. Fraud Prevention System Response Feedback: The Fraud Prevention System (FPS) is the state-of-the-art predictive analytics technology required under the Small Business Jobs Act of 2010 (SBJA).

Most Corporate Integrity Agreements require an IRO. What does this stand for? Answers: a. Independent Review Organization (IRO) b. Independent Recall Organization (IRO) c. Independent Revenue Organization (IRO) d. Independent Reorganization Organization (IRO)

Selected Answer: Correcta. Independent Review Organization (IRO) Response Feedback: Independent Monitor is the section that specifies the details of the Independent Review Organization (IRO) that most CIAs require, as well as the responsibilities of the provider towards the IRO.

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

Selected Answer: Correcta. Inform employees that internet usage is monitored Response Feedback: Inform employees that Internet use is recorded and stored, along with the source and destination.

If any employee is contacted by an outside agency regarding any issue within the organization, what is the first thing he/she should do? Answers: a. Notify the Compliance Officer immediately b. Help them get into the EHR c. Copy the requested records d. Call the other employees

Selected Answer: Correcta. Notify the Compliance Officer immediately Response Feedback: If any employee is contacted by an outside agency regarding any issue within the organization, he/she should notify the Compliance Officer immediately. There should be a written policy that all persons are to cooperate with governmental agencies, but that all matters should be handled through the Compliance Officer.

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

Selected Answer: Correcta. Providers billing fee-for-service are subjected to RAC audits. Response Feedback: If your practice or health care organization bills fee-for-service programs, your claims will be subject to review by the RACs.

The main task 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. Answers: a. SMRC b. CERT c. ZPIC d. RAC

Selected Answer: Correcta. SMRC Response Feedback: The Supplemental Medical Review Contractor's (SMRC) main tasks 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.

Many times a Compliance Committee will review provider documentation on a regular basis. When a practice identifies that a provider is an outlier, it becomes most important to verify that the billed services are what? Answers: a. submitted timely b. audited promptly c. documented and coded accurately d. scrubbed prior to submission

Selected Answer: Correctc. documented and coded accurately Response Feedback: If Medicare identifies a provider as an outlier it is not a forgone conclusion that the provider is submitting inappropriate claims, however, when a practice identifies that a provider is an outlier, it becomes prudent to verify that the billed services are both documented and coded accurately and appropriately.

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? Answers: a. Procedures b. Vital signs and HPI c. HPI d. Review of systems (ROS) or past family or social history (PFSH).

Selected Answer: Correctd. Review of systems (ROS) or past family or social history (PFSH). Response Feedback: Students are individuals who have not yet graduated from medical school. 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 review of systems (ROS) or past family or social history (PFSH).

Which one of the following is not an administrative sanction? Answers: a. Revocation of Medicare enrollment b. Exclusion c. Deactivation d. Revocation of Aetna enrollment

Selected Answer: Correctd. Revocation of Aetna enrollment Response Feedback: There is a wide range of administrative sanctions such as deactivation or revocation of Medicare enrollment or billing privileges, suspension of payments, or exclusion from participation in the Medicare Program.

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

Selected Answer: Correctd. Three Response Feedback: RACs will be only able to look back three years from the date the claim was paid.

The OIG Compliance Program Guidance acknowledges patient care as: Irrelevant to having an effective compliance program. They are not related. Important, but should not get in the way of implementing all seven recommended elements The first priority of a physician practice. The main reason offices fail to implement compliance programs In the first place.

The first priority of a physician practice. Compliance Officers (COs) should implement a "patients first" compliance model, and enlist buy-in from clinicians by demonstrating that compliance programs improve patient care.

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

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

PHI may be disclosed without the patient's authorization for ___________________. Death, Operations and Birth Certificates Treatment, Pictures and Operations Injections, Shots, and Research Treatment, Payment and Operations

Treatment, Payment and Operations PHI can be disclosed to another entity for treatment purposes, for quality or competency assurance activities, or fraud and abuse detection and compliance activities if both entities have or had a relationship with the patient and the PHI pertains to the relationship.

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. Moderate complexity and PPM procedures. High complexity and PPM procedures. PAP smear procedures.

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

Payers expect all providers to refund monies that are overpayments. By law, this must occur... A timely manner. Within 60 days of receipt of overpayment Within 60 days of identification of overpayment Within 90 days of a request by the payer.

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

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

Yes, PHI can be released for emergency treatment. PHI can be disclosed to another entity in emergency situations without consent if it's a usual disclosure, or with patient informal consent with the opportunity to agree or object.

Can an employee transfer a chemical to another container? No, all chemicals need to be kept in their original containers. Yes, as long as a secondary container label is used. No, an employer can receive hefty fines for transferring chemicals out of original containers. Yes, as long as the secondary container label is used and meets regulatory requirements.

Yes, as long as the secondary container label is used and meets regulatory requirements. All secondary containers will need to have labels that identify the contents, the name of the manufacturer, and the appropriate NFPA hazard warning labels

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

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

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. a. $50,000 b. $2,000 c. $10,000 d. $75,000

a. $50,000 HIPAA privacy regulations restrict the use, access, and disclosure of protected health information (PHI) and other individually identifiable health care information. 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 $50,000 per violation.

Patient Records of patients that have died are protected for how many years? a. 50 years b. Until the patient would have turned 18. c. Until the patient would have turned 21. d. 10 years

a. 50 years 50 years. HIPAA Privacy Rule (2013) protects the information of deceased patients for up to 50 years. The PHI is protected the same as if the patient was still alive.

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? a. Administrative safeguards b. Technical safeguards c. Facility safeguards d. Physical safeguards

a. Administrative safeguards Administrative safeguards administrative actions, policies, and procedures to manage the selection, development, implementation, and 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.

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

a. American Recovery and Reinvestment Act Response Feedback: American Recovery and Reinvestment Act of 2009 (ARRA) The Health Information Technology for Economic and Clinical Health Act (HITECH), which was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA), modified the HHS Secretary's authority to impose CMPs for violations occurring after February 18, 2009.

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? a. Anti-kickback b. Qui Tam c. Stark Law d. CMP

a. Anti-kickback Examples of the Anti- kickback statute violations: • A hospital providing rental rates that are below fair market value to a physician who refers business to their hospital • Routine waiver of co-payments 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 large amounts for speaking engagements by a company whom the provider refers business to

What is not a definition of an occupational exposure? a. Bruised skin b. A needle stick c. A percutaneous injury d. A cut with a sharp object

a. Bruised skin An occupational exposure is defined as a percutaneous injury (e.g. a needle stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g. exposed skin that is chapped, abraded or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.

Which organization publishes CLIA rules and regulation? a. CMS b. FDA c. CLIASA d. CDC

a. CMS CMS publishes the rules and regulations for CLIA

To enroll in the CLIA program, laboratories must first register by completing an application, pay fees, be surveyed, if applicable and become what? a. Certified b. Approved c. Funded d. Accredited

a. Certified To enroll in the CLIA program, laboratories must first register by completing an application, pay fees, be surveyed, if applicable and become certified. CLIA fees are based on the certificate requested by the laboratory (that is, waived, PPM, accreditation, or compliance) and the annual volume and types of testing performed.

What are the key functions of the Compliance Officer with regard to planning, implementing and monitoring the compliance program? a. Coordination and communication b. Auditing and monitoring c. Auditing and Communication d. None of the above

a. Coordination and communication Communication is extremely important, especially in large facilities such as hospitals. A Compliance Officer cannot be everywhere; therefore, it is imperative that he or she coordinates an action plan with other department leaders.

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? a. Corporate Integrity Agreement b. Central Intelligence Agency c. Clinical Integrity Agreement d. Corporate Intellectual Agreement

a. Corporate Integrity Agreement

Kim, Compliance Officer at Apple Rural Health Center, explains to her staff that OSHA falls under the _____________division of the government. a. DOL b. OIG c. CMS d. DOJ

a. DOL DOL. OSHA is the federal agency under the U.S. Department of Labor (DOL) charged with ensuring employee safety in the workplace.

The OIG imposed a CIA on Dr. K. The OIG also told Dr. K that he could no longer work for any entity that uses Federal or State money. This is an example of: a. Exclusion b. Discrimination c. LEP d. CMP

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

Employees that are exposed to Blood Borne Pathogens must be offered the Hep B Vaccination: a. For free. b. For the same cost that the facility purchased it and a slight profit to cover the administration. c. It is available to all employees at the local Health Department for a small administration fee. d. For the same cost that the facility purchased it.

a. For free. Free. The following statement of declination of hepatitis B vaccination must be signed by an employee who chooses not to accept the vaccine. The statement can only be signed by the employee following appropriate training regarding hepatitis B, hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and vaccinations are provided free of charge to the employee.

In February 1998, the OIG created the first compliance guidance document. What type of provider was the first Compliance Program Guidance issued for? a. Hospitals b. Third-Party Medical Billing Companies c. Durable Medical Equipment, Prosthetics, Orthotics, and Supply Industry d. Small Physician Practices

a. Hospitals The OIG created the first compliance guidance document for hospitals in February 1998.

Steve is the CPCO for Orange Labs. The CEO asked Steve if Laboratories should develop standards of conduct for employees? a. Laboratories should develop standards of conduct b. Laboratories only need to be concerned with Federal & State policies c. Laboratories can follow the same standards of conduct as other providers d. Laboratories are exempt for standards of conduct

a. Laboratories should develop standards of conduct Laboratories should develop standards of conduct for all employees that clearly delineate the policies of the laboratory with regard to fraud, waste and abuse and adherence to all statutes, regulations and other program requirements governing Federal, State and private health benefit plans.

What third-party is in a unique position of fraud discovery? a. Medical Billing Companies b. Providers c. Coders d. Billers

a. Medical Billing Companies Medical Billing Companies are in a unique position to discover various types of fraud, waste, abuse and mistakes on the part of the provider for which they furnish services.

Dr. Dallas requests a CBC on all his patients so he has a standing order for his patients that come to the lab for blood work. What should the lab do with the standing order? a. Monitor standing orders periodically b. Let his standing order stay until Dr. Dallas informs the lab he no longer wishes to have a CBC done on all his patients. c. Refuse to accept the standing orders. d. Have a written policy that allows standing orders to stay in place until provider request them to stop.

a. Monitor standing orders periodically Remember that an effective CPCO will monitor standing physician's orders periodically to make sure that they are still medical necessary and within compliance of the laboratory. They physician may have even forgotten about that standing order, so a good CPCO will have policy in place to monitor all standing orders.

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. a. No, laboratory may never ask a patient to sign a blank ABN b. Yes, this will protect the laboratory from patients not wanting to pay their bill when Medicare doesn't pay. c. No, the clinic needs to tell the patient the price of the service when they have them sign the ABN d. Yes, this is fine since it is a written policy of the clinical Laboratory

a. No, laboratory may never ask a patient to sign a blank ABN Laboratory must follow CMS rules in regards to ABNs and OIG considers this a risk area for Laboratories. Policies in place should be compliant with regulations.

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: a. Part A, B, C and D b. Part C and D only c. Part A and B only. d. Only A for hospitals

a. Part A, B, C and D Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. Civil monetary penalty (CMP) law and the False Claims Act (FCA) are related to proper claims billing. These bodies of law specify the criminal and/or civil remedies the government can impose upon individuals or entities that commit fraud and abuse in the Medicare program, including Medicare Parts C and D, and the Medicaid program.

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: a. September 2013 b. December 2008 c. January 2011 d. March 2009

a. September 2013 September 2013 The final omnibus rule, effective September 23, 2013, greatly enhances a patient's privacy protections, provides individuals new rights to their health information, and strengthens the government's ability to enforce the law via fines for breaches.

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? a. double billing b. waste c. fraud d. incentives

a. double billing Double Billing. Double Billing is when a provider bills for the same item or service more than once or another party billed the Federal healthcare program for an item or series also billed by the provider.

Penalties and exclusion from the Medicare program may be imposed on a _________________ who is convicted of repeated or "gross and flagrant" violations of EMTALA. a. physician b. hospital c. insurance payer d. patient

a. physician Physician Section 1395: penalties and exclusion from the Medicare program may be imposed on a physician who is convicted of repeated or "gross and flagrant" violations.

The Compliance Officer of Apple Internal Medicine Group explains to the Board that Stark law is similar to the ___________, but applies only to physician relationships with entities that bill Medicare or Medicaid. a. Exclusion Law b. Anti-kickback statute c. False Claims Act d. Self-Referral Law

b. Anti-kickback statute The Stark law is similar to the anti-kickback statute, but applies only to physician relationships with entities that bill Medicare or Medicaid. When enacted in 1989, the Stark law only applied to physician referrals for clinical laboratory services.

What employees should get Hepatitis B vaccines? a. Front desk employees only b. Any employee exposed to blood borne pathogens c. Physicians and nurses only d. All employees

b. Any employee exposed to blood borne pathogens Employees potentially exposed to blood or other infectious materials should be offered free Hepatitis B vaccines.

Who can initiate a Qui Tam action? a. Administrators only b. Any private party with independent knowledge of wrongdoing may c. Patients only d. Employees only

b. Any private party with independent knowledge of wrongdoing may Qui tam actions are a powerful weapon against health care fraud because a private party with independent knowledge of wrongdoing may initiate the action.

udy, 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? a. Survey b. Baseline c. Desk d. Shadow

b. Baseline The entire organization should be included in the initial, baseline audit to identify current compliance and areas of non-compliance. Specific areas of risk should be scrutinized more closely and more often.

Why did OSHA publish a Bloodborne Pathogens standard? a. Because of significant exposure to air-borne pathogens b. Because of significant exposures to viruses and other microorganisms c. Because of significant health risks d. Because of significant exposure to asbestos

b. Because of significant exposures to viruses and other microorganisms OSHA published the Occupational Exposure to Bloodborne Pathogens Standard in 1991 because of a significant health risk associated with exposure to viruses and other microorganisms that cause blood borne diseases.

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

b. Both parents have legal rights, unless ordered by judge otherwise Both parents have legal rights to child's records even if the parents are separated, divorced, or never married, unless ordered by a judge that one parent cannot access to the child's records.

Which of the following is NOT one of the 7 Elements of an Effective Compliance Plan? a. Responding appropriately to detect offenses and developing and implementing corrective action b. Conducting appropriate training and education c. Implementing compliance and practice standards d. Legal Council e. Conducting internal monitoring and auditing f. Developing open lines of communication g. Designating a Compliance Officer or contact h. Enforcing disciplinary standards through well publicized guidelines

d. Legal Council Legal Counsel. The seven elements are part of the Federal Sentencing Guidelines. The seven elements are part of each of the OIG's Compliance Guidelines. Legal Counsel is not one of the seven elements.

What usually happens next when settlement negotiations are unsuccessful? Answers: a. Trial b. CIA c. Investigations d. Litigation

d. Litigation Response Feedback: Litigation happens when settlement negotiations are unsuccessful. It is more likely to happen when there are whistleblowers involved who convince an attorney there is significant money to be made. Thus in settlement negotiations, it's important to educate the opposing counsel.

The Office of Evaluation and Inspections is part of what Agency or Department? a. DOJ b. Department of Audits c. CMS d. OIG

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

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

d. Office of Audit Services Office of Audit Services - performed independent audits of HHS programs and/or HHS grantees and contractors to examine their performance.

A Compliance Corrective Action Plan might deal with which of the below item? a. Nurse steals injections b. Employee alters their time card c. CEO takes too much time off from work d. Provider does not complete documentation timely

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

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? a. between 20 and 25 percent b. 50 percent c. between 25 and 30 percent d. between 15 and 25 percent

d. between 15 and 25 percent If the government intervenes in the qui tam action, the relator is entitled to receive between 15 and 25 percent of the amount recovered by the government through the qui tam action. If the government declines to intervene in the action, the relator's share is increased to 25 to 30 percent.

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

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

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 ____________? a. been noted in the new plan and the group will try to be better about compliance next year b. not created any issues so all is well c. created issues that will cause huge fines to be given to the practice d. 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

d. 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 Levels of non-compliance include (1) intentional or reckless disregard for policies and regulations (2) failure to detect violation (3) failure to report a violation. All employees, regardless of rank need to be held accountable for non-compliance.

Alerts for Physician's Office labs from Medicare on expired certificate, will cause your Medicare carrier to a. Medicare carrier does not know the status of your certificate b. continue to pay at the current rate c. pay at a lower rate during the alert d. deny claims

d. deny claims Medicare carriers are advised by CMS to begin denying claims for diagnostic clinical laboratory test performed in physician office effective July 1, 1997.

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? a. payment b. ordering tests c. billing for claims d. enrollment

d. enrollment The Patient Protection and Affordable Care Act of 2010 (ACA) requires that all providers adopt a compliance plan as a condition of enrollment with Medicare, Medicaid and CHIP.

Compliance programs are... not mandated by law. effective after the baseline audit has been performed and policies written. only required by law for healthcare entities that have more than $500,000 in annual revenue. more dangerous if they are developed but not implemented.

more dangerous if they are developed but not implemented. The only thing worse than not having a Compliance Program is to have a Compliance Program that is not implemented.

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 ... only if the patient has Medicare Part A. only if the patient has Medicare Part B. only when the patient is uninsured. regardless of the patient's insurance or ability to pay.

regardless of the patient's insurance or ability to pay. The purpose of EMTALA is to prevent hospitals from rejecting patients, refusing treatment to patients, or transferring patients to "charity hospitals" or "county hospitals" because they are unable to pay for services or are covered by Medicare or Medicaid programs. In essence, EMTALA is a non-discrimination statute. EMTALA requires that hospitals accepts Federal funding provide to any patient who comes to the emergency department at least a medical screening exam, to determine if an emergency medical condition exists.

What is OSHA? a. Ohio Safety Hospital Association b. A federal agency in charge of employee safety c. A state agency in charge of employee safety d. Occupational Service and Hospital Associates

b. A federal agency in charge of employee safety The Occupational Safety and Health Administration (OSHA) is the federal agency charged with ensuring employee safety in the workplace

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: a. Misuse of resources b. Waste c. Abuse d. Fraud

b. Waste Medicare defines waste as a medically unnecessary service.

What is one way to discourage whistleblowers found in this chapter? Selected Answer: Answers: Write policies and procedures Conduct performance reviews Perform background checks for office personnel Query the OIG and GSA databases for excluded individuals.

Correct Conduct performance reviews Response Feedback: To discourage whistleblowers, performance reviews are a good time for people to acknowledge concerns in writing, and to explain whether (and how) previously noted concerns have been addressed.

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

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

Welfare Benefit plans include: Selected Answer: Answers: Retirement Plans Fringe Benefits Pension Benefits All of the above

Correct Fringe Benefits Response Feedback: This covers a broad range of fringe benefit plans (everything except retirement plans.)

PAR means what? Answers: Physicians agree to take assignment on all Medicare claims Physicians will not take assignment on all Medicare claims Physicians agree to take 100% on all Medicare claims Physicians agree to reassign payment on all Medicare claims

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

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

Department of Justice (DoJ) More than 114,000 employees, including hundreds of lawyers, ensure that the Department of Justice (DOJ) carries out the individual missions of its components.

Which federal government departments is the OIG not responsible for overseeing? Centers for Medicare & Medicaid Services (CMS) Centers for Disease Control and Prevention (CDC) U.S. Food & Drug Administration (FDA) Drug Enforcement Agency (DEA)

Drug Enforcement Agency (DEA) 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.

Which department is the largest inspector general's office in the federal government? Office of Inspector General (OIG) U.S. Department of Health & Human Services (HHS) Department of Justice (DoJ) Centers for Medicare & Medicaid Services (CMS)

Office of Inspector General (OIG) The OIG is the largest inspector general's office in the federal government, with more than 1,700 workers dedicated to combating fraud, waste, and abuse.

Skilled Nursing Facilities (SNFs) are Medicare certified facilities that provide extended skilled nursing or rehabilitative care under Medicare Part ____. A B C Part A and Part B

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

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? A compliance program will not be effective unless every element is fully implemented? Have a manual of Policies and procedures available for review in the manager's office? Small practices are low risk so they don't need to implement a compliance program?

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

What should be readily accessible to all coding staff? Billing certification CPT™ codebook All essential coding resources Nursing handbook

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

What are designated health services? Clinical Laboratory services Physical therapy services Home health services All of the above

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

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

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

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

Business associates Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence, with a maximum penalty of $1.5 million per violation.

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 Compliance Certificate for Provider-performed Microscopy (PPM) procedures Certificate of Registration Certificate of Waiver

Certificate of Registration This 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.

If a referred patient to your practice has hearing deficit and needs an appointment, what steps should your practice take when scheduling? Selected Answer: Answers: Ask the patient to bring an interpreter with them to the visit. Kindly explain to the patient that he or she can't be seen because the practice doesn't have the ability to communicate with them. Schedule the appointment a few days ahead to make arrangements for an interpreter. Schedule the appointment, advise the patient of the charge for the interpreter, and ask how he or she will pay for the services.

Correct Schedule the appointment a few days ahead to make arrangements for an interpreter. The ADA requires businesses to take steps necessary to communicate effectively with patients with vision, hearing, and speech disabilities.

Which is the underlying principal of the Equal Employment Opportunity law? Selected Answer: Answers: This law requires all persons be entitled to equal employment salary regardless of race, religion, or national origin. This law requires all minorities be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. This law requires all persons be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. This law requires all persons be entitled to equal employment opportunity regardless of sex, age, or disability.

Correct This law requires all persons be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. Response Feedback: It is important for a compliance officer to understand that all persons are legally entitled to equal employment regardless of their race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. Failure to abide by the Equal Employment Opportunity law can bring forth lawsuits based on unlawful discrimination. See www.eeoc.gov for information about this law and example cases.

How many agencies oversee ERISA? Selected Answer: Answers: One Two Three Four

Correct Three Response Feedback: Three agencies oversee ERISA: IRS, DOL, and PBGC.

Which one of the following is not a corrective action resulting from an audit? Answers: a. Conducting educational sessions for provider and all clinical staff b. Refining improper payment rate measurements c. Updating coverage policies and manuals d. Improving system edits

Correcta. Conducting educational sessions for provider and all clinical staff Response Feedback: Corrective actions include conducting provider education efforts, but not for their clinical staff.

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

Correctb. Center for Program Integrity Response Feedback: The ZPICs and the MEDIC work under the direction of the Center for Program Integrity (CPI) in CMS.

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? Answers: a. 12 weeks b. 10 weeks c. 26 weeks d. 36 weeks

Correctc. 26 weeks Response Feedback: As of January 28, 2008, qualifying employees may utilize up to 12 weeks of medical leave in any 12-month period if a "qualifying exigency" arises out of a covered family member's active duty or call to active duty in the Armed Forces in support of a contingency plan; and/or up to 26 weeks in a single 12-month period to care for a covered family member who has incurred an injury or illness in the line of duty while on active duty in the Armed Forces, provided that such injury or illness renders the family member medically unfit to perform duties of his or her office, grade, rank, or rating.

Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well _________ Answers: a. Medicare Advantage Abuse b. Workers Compensation Fraud c. Patent Abuse d. Medicare Fraud

Correctc. Patent Abuse Response Feedback: Patient Abuse. Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect in health care facilities and board and care facilities

Which of these statements are not true about ZPICs? Answers: a. Investigates (determines the factual basis of) allegations of fraud made by beneficiaries, providers, CMS, OIG, and other sources b. Refers cases to the Office of the Inspector General/Office of Investigations for consideration of civil and criminal prosecution and/or application of administrative sanctions c. Proactively identifies incidents of potential fraud that exist outside of its service area d. Initiates appropriate administrative actions to deny or to suspend payments that should not be made to providers where there is reliable evidence of fraud

Correctc. Proactively identifies incidents of potential fraud that exist outside of its service area Response Feedback: ZPICs do not proactively identify incidents of potential fraud that exist within its service area, nor take appropriate action on each case

Health information that does not identify an individual is called _______________. Cloned Information De-identified Information Re-identified Information Misidentified Information

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

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. No, a CLIA number is not required if the facility only collects specimens and performs minor testing. Yes, a CLIA number is required if the facility only collects specimens even if they perform no testing. Yes, a Medicare-participating provider that only collects specimens requires a CLIA number.

No, a CLIA number is not required if the facility only collects specimens and performs no testing. Labs do not require a CLIA number if they only collect specimens and perform no testing.

What policy is written to encourage communication? Attendance Policy Electronic Protected Information Policy Non-retaliation Policy Safety & Security Management Policy

Non-retaliation Policy A Non-retaliation Policy for everyone, including employees & patients is an important part of the Compliance Program to encourage communication, asking questions, obtaining clarification of policies and procedures outlined in the Compliance Program, and reporting of all incidents of potential misconduct.

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

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

What can providers review that will help them understand the compliance requirements of a clinical lab? Laboratory Provider Handbook OIG's Clinical Lab Guidance OIG Developing an Effective Compliance Program Physician Desk Reference

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

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

Occupational Safety and Health Administration The Occupational Safety and Health Administration (OSHA) is the federal agency charged with ensuring employee safety in the workplace.

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 is she referring to? Employment Equality Agency (EEA) Office for Civil Rights (OCR) Department of Justice (DoJ) Office of Inspector General (OIG) Response Feedback:

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

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

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

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

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

HITECH revisions significantly increased the penalty amounts the Secretary may impose for violations of______________? Answers: CLIA OSHA FCA HIPAA

Selected Answer: Correct HIPAA Response Feedback: These HITECH Act revisions significantly increased the penalty amounts the Secretary may impose for violations of the HIPAA rules, encouraging prompt corrective action.

What is the level 3 of the RAC Claims appeals process? Answers: Redetermination by a MAC Reconsideration by a Qualified Improvement Contractor (QIC) Hearing by an Administrative Law Judge (ALJ) Review by the Medicare Appeals Council within the Departmental Appeals Board

Selected Answer: Correct Hearing by an Administrative Law Judge (ALJ) Response Feedback: Level three of claims appeals is a Hearing by an Administrative Law Judge ALJ

After an audit reveals areas for improvement, what is the next step a Compliance Officer should take? Answers: Call a staff meeting Implement corrective action plans Schedule an investigation only Notify the board

Selected Answer: Correct Implement corrective action plans Response Feedback: After an audit reveals areas for improvement, corrective action plans should be implemented.

Under MSP, the Medicare statute and regulations require all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether_______________. Answers: Medicare is the primary payer for those items or services. Medicare is always a secondary payer for those items or services. Workers' Compensation is the primary payer for those items or services. Medicaid is the primary payer for those items or services.

Selected Answer: Correct Medicare is the primary payer for those items or services. Response Feedback: The MSP provisions apply to situations when Medicare is not the beneficiary's primary health insurance coverage. Medicare statute and regulations require all entities that bill Medicare for items or services rendered to beneficiaries must determine whether Medicare is the primary payer for those items or services.

When creating handicap parking spaces, which is true with regard to 4 or less spaces? Answers: No handicap sign is required as long as there is an access aisle. One out of every five spaces must be van accessible. ADA must come and inspect the parking lot first. The handicap sign is required to be 6 inches wide by 14 inches high.

Selected Answer: Correct No handicap sign is required as long as there is an access aisle. Response Feedback: An accessible parking space must have an access aisle, which allows a person who uses a wheelchair or other mobility device to get in and out of the car or van. No signage is required.

Which office provides guidance to the healthcare industry in the form of Advisory Opinions, Special Fraud Alerts, Special Advisory Bulletins, and Compliance Program Guidance? Answers: CMS MAC Attorney General OIG

Selected Answer: Correct OIG Response Feedback: In addition to working with law enforcement partners to sanction companies and individuals who violate the law, OIG also commits substantial resources to promote voluntary compliance by the health care industry. They provide guidance to the healthcare industry in the form of Advisory Opinions, Special Fraud Alerts, Special Advisory Bulletins, Compliance Program Guidance, and offer substantive assistance to program participants committed to promoting ethical and lawful conduct in their organizations.

Which office's main responsibility is it to investigate healthcare fraud, waste, and abuse? Answers: CMS MAC Attorney General OIG

Selected Answer: Correct OIG Response Feedback: The Office of Inspector General's (OIG) main responsibility is to investigate healthcare fraud and abuse.

Medicaid Fraud Control Units (MFCUs) operate under the direction of _______. Answers: Center for Medicare & Medicaid Services (CMS) Department of Insurance Office of Inspector General (OIG) Recovery Audit Contractors (RAC)

Selected Answer: Correct Office of Inspector General (OIG) Response Feedback: Each Unit operates under the administrative oversight of the OIG.

Which serves as a reference source of information about personnel policies and procedures? Answers: Nursing Handbook Personnel Policy Manual Physician Desk Reference Material Safety Data Sheets

Selected Answer: Correct Personnel Policy Manual Response Feedback: Personnel policy manuals should be designed to serve as a reference source of information about personnel policies and procedures.

What does Medicare Part D cover? Answers: Skilled Nursing Durable Medical Equipment Hospital Prescription Drugs

Selected Answer: Correct Prescription Drugs Response Feedback: Medicare Part D is a program for prescription drug plans

Should employees be allowed to download software? Answers: a. Yes, as long as it has a license b. No, because it can bring unknown viruses to computers c. Yes, as long as it is authorized d. No, they cannot download software

Selected Answer: Correctc. Yes, as long as it is authorized Response Feedback: They should never download or install unauthorized software, and there should be a process for approving software.

Advanced Beneficiary Notices should be presented: Answers: To every patient, in case the service or procedure is not paid by Medicare. Prior to when a service is not a covered benefit/service of Medicare because it is not considered medically reasonable and necessary. When a patient cannot pay for the services rendered and will not be financially liable. Never, as it may upset the patient.

Selected Answer: Correct Prior to when a service is not a covered benefit/service of Medicare because it is not considered medically reasonable and necessary. Response Feedback: To bill a traditional Medicare patient for most outpatient services that aren't covered by Medicare, the patient must receive an advance beneficiary notice (ABN) before the services are provided. It is given prior to providing an item or service that is usually paid for under Medicare Part B (or under Part A for hospice, HHA, and RNHCI providers), but may not be paid in this particular case because it is not considered medically reasonable and necessary.

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

Selected Answer: Correct Request an attorney Response Feedback: Employees should know they are not required to speak with an agent, and can request an attorney if they choose.

Employees should be told that if they are questioned in an investigation they should always what? Answers: Tell their side of the story Bring patient records to the interview Stick to the facts and don't speculate Refuse to cooperate and go home

Selected Answer: Correct Stick to the facts and don't speculate

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

Selected Answer: Correct The CPT® and diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Response Feedback: Remember: If it isn't documented, it wasn't done.

Modifier 25 is used to allow additional payment for E/M services performed by a provider on the same day as a procedure, as long as ____________. Answers: The E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are on the same day, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are minimal, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. The E/M services are significant, related to the last visit, and above and beyond the usual preoperative and postoperative care associated with the procedure.

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

What sets ZPIC audits apart from other Medicare audits? Answers: The audits are alphabetically done by zone The audits are targeted by potential Medicare fraud The audits are performed nationwide The audits are performed in zones

Selected Answer: Correct The audits are targeted by potential Medicare fraud Response Feedback: While ZPIC audits are similar in many ways to other Medicare audits currently being performed nationwide, they do differ in one very important aspect: potential Medicare fraud implications.

What description below best describes ZPICs? Answers: ZPICs are federal companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments ZPICs are state companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments ZPICs are private companies contracted by CMS, used to conduct audits for Medicare and Medicaid overpayments ZPICs are private companies contracted by the OIG, used to conduct audits for Medicare and Medicaid overpayments

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

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. Answers: a. 18, 29, 36 months b. 18, 26, 48 months c. 18, 20, 26 months d. 12, 16, 20 months

Selected Answer: Correcta. 18, 29, 36 months Response Feedback: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) created a duty for employers to provide continuation of certain employer-sponsored health plan coverage to covered individuals, spouses, and dependents who experience a qualifying event that results in a loss of coverage. The employer must permit "qualified beneficiaries" to elect to continue their health insurance under the plan for 18, 29, or 36 months, depending on the "qualifying event" that entitles the person to coverage.

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

Selected Answer: Correcta. 2003 Response Feedback: On December 8, 2003, the Medicare Modernization Act (MMA) was signed into law

The typical CIA agreement lasts for how long? Answers: a. 3-5 years b. 10 + years c. 0-6 months d. 1-4 years

Selected Answer: Correcta. 3-5 years Response Feedback: The Term and Scope of the CIA is that section that identifies the length of the agreement (usually three to five years but could be as little as two years and as much as eight years); and gives certain definitions to explain the scope and coverage of the CIA. This section usually is tailored to the respective provider.

John explains to the providers and staff at ABC Medical Group that CERT looks at the following concerns: Answers: a. Only concerns with Medicare Part C and D billings. b. No documentation, insufficient documentation, medical necessity and incorrect coding c. Fraud, waste and abuse d. Only Medicaid billings

Selected Answer: Correctb. No documentation, insufficient documentation, medical necessity and incorrect coding Response Feedback: No documentation, insufficient documentation, medical necessity and incorrect coding. CMS implemented the federally mandated CERT program to establish error rates and estimates of improper payments in compliance with the Improper Payments Elimination and Recovery Improvement Act (IPERIA). CMS took over improper payment measurement in 2001, and reported its first improper payment rate in November 2003. Each year, CERT evaluates a statistically valid random sample of claims (50,000 to date) to determine if CMS was paid properly under Medicare coverage, coding, and billing rules. Multiple improper payment rates are computed as follows: Nationally By contractor By service By provider type

What Department monitors and recertifies MFCUs? Answers: a. CMS b. OIG c. CMS d. DOJ

Selected Answer: Correctb. OIG Response Feedback: Correct Answer Reply: The OIG reviews and certifies each MFCU every year, and monitors whether they are complying with statutes, regulations, and OIG policies.

Hannah is the Compliance Officer for Orange Hospital. She is explaining to her mother that Medicare Part B pays for what type of services? Answers: a. Hospice b. Physician c. Inpatient d. Pharmacy

Selected Answer: Correctb. Physician Response Feedback: Medicare Part B pays for services that physicians provide to program beneficiaries.

______ detect and correct past improper payments so that CMS and carriers, fraud investigators, and ______ can implement actions that will prevent future improper payments. Answers: a. OIG/RACs b. RACs/MACs c. MACs/RACs d. CMS/RACs

Selected Answer: Correctb. RACs/MACs Response Feedback: RACs/MACs. RACs detect and correct past improper payments so that CMS and carriers, fraud investigators, and MACs can implement actions that will prevent future improper payments. In turn: Providers can avoid submitting claims that do not comply with Medicare rules; CMS can lower its error rate; and Taxpayers and future Medicare beneficiaries are protected from fraud.

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

Selected Answer: Correctb. The state licensing board Response Feedback: Improper advertising can get the physician in trouble with the state licensing board.

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

Selected Answer: Correctb. ZPICs are private companies contracted by CMS Response Feedback: ZPICs are private companies contracted by the CMS, used to conduct audits for Medicare and Medicaid overpayments.

Haanh, the Compliance Officer for Orange Hospital explained to the Board that a principle element of a billing and reimbursement compliance program is to have a compliance officer who is_________________? Answers: a. a certified coder b. empowered c. friends with the board members d. a billing manager

Selected Answer: Correctb. empowered Response Feedback: A principle element of a billing and reimbursement compliance program is an effective and empowered compliance officer or committee.

When hiring counsel, the most important quality you should require is_____________? Answers: a. ability to travel b. experience c. affordable rates d. a local office

Selected Answer: Correctb. experience Response Feedback: Hiring the right counsel is a very important step in an investigation. You are going to want counsel with experience handling investigations.

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 ______. Answers: a. a fellow b. not a resident c. a resident. d. not the chief of staff

Selected Answer: Correctb. not a resident Response Feedback: Regulations provide 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 or the services are furnished by a resident in the presence of a teaching physician or the teaching physician must be present during the key portion of any service or procedure for which payment is sought.

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 _____________? Answers: a. requirements are not met for procedures only b. requirements are not met c. requirements are met d. requirements are met for a 99211 service only

Selected Answer: Correctb. requirements are not met Response Feedback: The physician or mid-level that bills for the service needs to be in the office and immediately available. If the provider is available only via pager or telephone, incident-to billing cannot be completed.

The term ________ refers to the altering or destroying of records that could be used as evidence. Answers: a. rendering b. spoliation c. shred d. white out

Selected Answer: Correctb. spoliation Response Feedback: Spoliation. The term spoliation refers to the altering or destroying of records that could be used as evidence.

As the Compliance Officer, Kim needs to review and revise certain policies yearly or as laws change. The CEO thinks that the policies should be unique to the office and specifically address some HR issues that have occurred recently. It is recommended to write documents with the thought that ________ Answers: a. there will be a law suit. b. the government could review them someday. c. they could be on the front page of the newspaper someday. d. an employee will be a whistleblower.

Selected Answer: Correctb. the government could review them someday.

A Board member at the XYZ Community Hospital inquires what the term EAP refers to? Answers: a. Employee Assisted Plans b. Employment Assistance Programs c. Employee Aided Programs d. Employee Assistance Plans

Selected Answer: Correctd. Employee Assistance Plans Response Feedback: Employee Assistance Plans (EAPs) are a good way to help employees address personal issues that can affect job performance.

As the Compliance Officer, Kim needs to review and revise certain policies yearly or as laws change. The CEO thinks that the policies should be unique to the office and specifically address some HR issues that have occurred recently. It is recommended to write documents with the thought that ________ Answers: a. there will be a law suit. b. the government could review them someday. c. they could be on the front page of the newspaper someday. d. an employee will be a whistleblower.

Selected Answer: Correctb. the government could review them someday. Response Feedback: Sometimes, the government may ask a provider to waive privilege for audit reports that were initially intended to be attorney-client privileged. There also are many cases where privileged material gets mistakenly provided. It is recommended to write documents with the thought that the government could review them someday

Once a vulnerability or risk has been identified it is important to determine the risk rating. This is determined by_______________? Answers: a. the rate of occurrence and the severity of impact b. the likelihood or probability of occurrence and the severity of impact c. the possibility of occurrence and the severity of impact d. the history of occurrence and the severity of impact

Selected Answer: Correctb. the likelihood or probability of occurrence and the severity of impact Response Feedback: Once a vulnerability or risk has been identified it is important to determine the risk rating. This is determined by the likelihood or probability of occurrence and then the severity of impact if it does occur.

CIAs almost always include provisions incorporating _________ but the specific terms of a particular CIA depend on the facts and circumstances related to that case and that provider. Answers: a. an Independent Review Organization b. the seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines. c. expert witness testimony that elaborates on why there is a CIA d. civil monetary payments or other fines.

Selected Answer: Correctb. the seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines. Response Feedback: The seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines. CIAs almost always include provisions incorporating the seven elements of an effective compliance program, as is found in the OIG's compliance program guidelines, but the specific terms of a particular CIA depend on the facts and circumstances related to that case and that provider. Among the relevant factors considered in crafting a CIA are the 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.

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? Answers: a. HIPAA b. their specific job descriptions c. OSHA d. the medical record department

Selected Answer: Correctb. their specific job descriptions Response Feedback: Training, as an element of a billing and reimbursement compliance program, is essential. If the employees of the practice/organization are not aware of the compliance issues and the applicable laws and regulations that pertain to their specific job descriptions, then the organization's billing and reimbursement compliance program will flounder.

What year was the ADA amendment enacted? Answers: a. 2006 b. 2007 c. 2008 d. 2009

Selected Answer: Correctc. 2008 Response Feedback: The ADA was established in 2008.

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? Answers: a. Written directives b. A participation contract c. A corporate integrity agreement d. A compliance program

Selected Answer: Correctc. A corporate integrity agreement Response Feedback: Among the relevant factors considered in crafting a CIA are the 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.

A patient is considered new if they meet which of the following criteria? Answers: a. A patient who has not received any professional services from the physician or another physician of a different specialty who belongs to the same group practice within the past three (3) years b. A patient who has not received any professional services from the physician within the past three (3) years c. A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years d. A patient who was seen in the hospital but has not received any office visits from the physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years

Selected Answer: Correctc. A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years Response Feedback: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three- (3) years.

If physicians sign a participating (PAR) agreement with Medicare, they agree to what? Answers: a. Bill patients for more than the Medicare allowance b. Forego any payments from Medicare c. Accept Medicare's allowed charge as payment in full d. Agreeing to bill patients directly

Selected Answer: Correctc. Accept Medicare's allowed charge as payment in full Response Feedback: There are basically three Medicare contractual options for physicians. Physicians may sign a participating (PAR) agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients. They may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Or they may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves.

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

Selected Answer: Correctd. MAC Response Feedback: The Medicare program has program manual instructions on overpayments. Generally, overpayments are returned to the MAC.

In addition to working with law enforcement partners to sanction companies and individuals who violate the law, the OIG also commits substantial resources to promote voluntary compliance by the healthcare industry. They provide guidance to the healthcare industry in the form of: Answers: a. Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; Free Hot Line service for non-exempt employees. b. Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; Legal counsel c. Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; Compliance Program Guidance d. Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; IRO selection

Selected Answer: Correctc. Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; Compliance Program Guidance Response Feedback: Advisory Opinions, Special Fraud Alerts; Special Advisory Bulletins; Compliance Program Guidance. In addition to working with law enforcement partners to sanction companies and individuals who violate the law, OIG also commits substantial resources to promote voluntary compliance by the healthcare industry. They provide guidance to the healthcare industry in the form of Advisory Opinions, Special Fraud Alerts, Special Advisory Bulletins, Compliance Program Guidance, and substantive assistance to program participants committed to promoting ethical and lawful conduct in their organizations.

Which area would not be considered during a performance review? Answers: a. An employee's compliance with Corporate Compliance Program b. An employee's attitude toward patients c. An employee's attendance at company party d. An employee's attitude toward fellow employees

Selected Answer: Correctc. An employee's attendance at company party Response Feedback: An employer cannot consider the attendance of a company party as part of scoring for a performance review.

In certain cases, a provider, practitioner or supplier who routinely waives Medicare copayments or deductibles also could be held liable under what law? Answers: a. Qui tam b. FCA c. Anti-Kickback Statute d. Stark

Selected Answer: Correctc. Anti-Kickback Statute Response Feedback: In certain cases, a provider, practitioner or supplier who routinely waives Medicare copayments or deductibles also could be held liable under the Medicare and Medicaid anti-kickback statute. 42 U.S.C.1320a-7b (b).

Which of the following is not an example of sexual harassment? Answers: a. Repeatedly asking another employee to date after they've declined b. Sexual advances c. Asking another employee to date d. Request for sexual favors

Selected Answer: Correctc. Asking another employee to date Response Feedback: Sexual harassment includes the following: sexual advances, requests for sexual favors, or other verbal or sexual conduct that becomes an explicit or implicit condition affecting someone's job or duties.

What department monitors the MACs? Answers: a. RACs b. ZPICs c. CERT d. OIG

Selected Answer: Correctc. CERT Response Feedback: CERT programs monitor the work of MACs to include claims payment and denials.

John is the Compliance Officer for ABC Medical Group. One of the providers asks him what does the acronym CERT sand for? John replies: Answers: a. Comprehensive Error Rate Technology b. Certified Error Rate Technology c. Comprehensive Error Rate Testing d. Certified Entry Rate Technology

Selected Answer: Correctc. Comprehensive Error Rate Testing Response Feedback: Comprehensive Error Rate Testing

The ______ is one of the primary investigation agencies that assist the federal prosecutors. Answers: a. OIG b. OCR c. FBI d. DOJ

Selected Answer: Correctc. FBI Response Feedback: The FBI is one of the primary investigation agencies that assist the federal prosecutors.

Independent Monitor specifies the details of the _________ most CIAs require, as well as the responsibilities of the provider towards the _________. Answers: a. Compliance Officer b. Compliance Expert c. IRO d. All of the above

Selected Answer: Correctc. IRO Response Feedback: Independent review organization (IRO) Independent Monitor specifies the details of the independent review organization (IRO) most CIAs require, as well as the responsibilities of the provider towards the IRO.

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

Selected Answer: Correctc. IRS, DOL, PBGC all have separate penalty assessments Response Feedback: IRS, DOL, and PBGC all have separate penalty assessments.

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

Selected Answer: Correctc. Medicaid Fraud Control Units Response Feedback: Medicare Fraud Control Units, annually certified by the US Department of Health and Human Services, conducts a statewide program for the investigation and prosecution of health care providers that defraud the Medicaid program.

Which type of employee must be paid overtime? Answers: a. Exempt b. Administration c. Non Exempt d. Management

Selected Answer: Correctc. Non Exempt Response Feedback: Non-exempt, hourly employees must be paid overtime in accordance with state and federal laws. Supervisor responsibilities when deciding to use overtime, how to ask employees to perform overtime, and when overtime is no longer necessary, should be clear.

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? Answers: a. For attorney client privilege b. An attorney knows the best audit processes c. The government or opposing party may obtain a copy d. In the event there is an overpayment demand

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

Free statistical software that can be used to select a random sample for audit is called what? Answers: a. 3M Grouper b. Audit Pro c. IRO d. RAT-STATS

Selected Answer: d. RAT-STATS Response Feedback: RAT-STATS is a free statistical software that can be used to select a random sample for audit. The software is available on the OIG website.

The Preamble establishes the statutory basis for the CIA and _____. It includes the statement that the CIA is intended to "promote compliance with the statutes, regulations and written directives of Medicare, Medicaid, and all other federal healthcare programs" Answers: a. amount owed b. lists of all excluded parties c. the date it was first entered d. names of the CEO, Compliance Officer and Board Members

Selected Answer: Correctc. the date it was first entered Response Feedback: The date it was first entered. All CIAs contain standard components distinguished one from the other by the specifics for the particular allegations and vendor involved. The Preamble establishes the statutory basis for the CIA and the date it was first entered. It includes the statement that the CIA is intended to "promote compliance with the statutes, regulations and written directives of Medicare, Medicaid, and all other federal healthcare programs" (see "Corporate Integrity Agreement Between the Office of Inspector General of the Department of Health and Human Services and Eli Lilly and Company").

Which statement is TRUE regarding the fact that the company does not need to file an ERISA report if: Answers: a.the plan has more than 100 participants b.the plan is 75% covered by insurance c.the plan has assets d.the plan has less than 100 participants

Selected Answer: Correctd. the plan has less than 100 participants Response Feedback: The plan has less than 100 participants. No ERISA reporting is required as long as: The plan has no assets (for ERISA purposes, "assets" are a separate trust fund distinct from the general assets of the employer); or The plan is 100 percent covered by insurance and has less than 100 participants.

John, Compliance Officer for ABC Family Medical Group explains to operations that when billing a traditional Medicare patient for services that aren't covered by Medicare, the patient must receive an__________? Answers: a. Explanation of benefits b. Out of network agreement c. Authorization on file d. ABN

Selected Answer: Correctd. ABN Response Feedback: To bill a traditional Medicare patient for services that aren't covered by Medicare, the patient must receive an advance beneficiary notice (ABN) before the services are provided.

After Kim explains to the Apple Rural Health Center why EEOC is important, a Board member asks her to explain what ADA stands for: Answers: a. American Discharge Act b. Americans Disabled Agreement c. American Disadvantage Act d. American with Disabilities Act

Selected Answer: Correctd. American with Disabilities Act Response Feedback: Title I of the Americans with Disabilities Act and the ADA Amendments Act of 2008.

Sarah, Compliance Officer for Apple Hospital, explains to the hospital Board that the ______ governs relationships between competitors? Answers: a. Anti-kickback Statute b. FCA c. Gainsharing d. Antitrust

Selected Answer: Correctd. Antitrust Response Feedback: The antitrust laws govern relationships between competitors. Health care providers, including physicians, have been the subjects of antitrust scrutiny for many years.

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

Selected Answer: Correctd. Assistance with developing new compliance plans for the providers that have failed audits in the past. Response Feedback: Assistance with developing new compliance plans for the providers that have failed audits in the past. The cornerstone of the MACs' efforts to prevent improper payments is each contractor's Error Rate Reduction Plan (ERRP), which includes initiatives to help providers comply with the rules.

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________: Answers: a. Automated and Non Automated. b. Automated and Simple c. Automated and Intermediate d. Automated and Complex

Selected Answer: Correctd. Automated and Complex Response Feedback: Automated and Complex. RACs review claims on a post-payment basis by using the same Medicare policies as carriers, fraud investigators, and MACs including NCDs, LCDs, and CMS manuals. There are two types of reviews: · Automated (no medical record needed) · Complex (medical record required)

It is important to explain to the staff that retaliation between employees "I can get Suzie in trouble because she irritates me and I want her fired" is considered what type of reporting? Answers: a. HR reporting b. Good faith reporting c. Disciplinary reporting d. Bad faith reporting

Selected Answer: Correctd. Bad faith reporting Response Feedback: It is important to explain to the staff the difference between good faith reporting and bad faith reporting. Retaliation between employees "I can get Suzie in trouble because she irritates me and I want her fired" would be bad faith reporting. Also, if the reporter is involved in the instance of non-compliance, there will be no retaliation for the reporting, but he/she will be disciplined in the appropriate manner for the non-compliance.

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 _______ Answers: a. Modifiers b. HCPCS codes c. CPT code d. Diagnosis Code

Selected Answer: Correctd. Diagnosis Code Response Feedback: Some of the most common reasons for claims not being paid in the current reimbursement environment are related to the diagnosis. The basic requirement is that the diagnosis must justify the procedure performed and documented in the medical record. Diagnosis codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the complexity of the E/M services provided.

What should never be tolerated by an employer? Answers: a. Attitude of employees b. Gossip by employees c. Extended lunch times d. Discrimination

Selected Answer: Correctd. Discrimination Response Feedback: Employees should be made aware that discrimination is not tolerated in the workplace.

Few cases go to trial. In today's courts there is tremendous pressure from the presiding judge to work out a settlement. The provider will have a couple of opportunities to get the case dismissed. Answers: a. False, the OIG is trying to increase the number of trials due to an increase in healthcare crime. b. True, but the provider does not have any opportunities to get the case dismissed. c. False d. True

Selected Answer: Correctd. True Response Feedback: Litigation happens when settlement negotiations are unsuccessful. It is more likely to happen when there are whistleblowers involved who convince an attorney there is significant money to be made. Thus in settlement negotiations, it's important to educate the opposing counsel. Few cases go to trial. In today's courts there is tremendous pressure from the presiding judge to work out a settlement.

After Carol, Compliance Officer for XYZ Internal Medial Group identifies a provider as an outlier or different vulnerabilities are identified with risk ratings, an important next step is to develop_________? Answers: a. an audit and disciplinary actions b. training and corrective action plan c. an audit and additional training d. an audit and corrective action plan

Selected Answer: Correctd. an audit and corrective action plan Response Feedback: After a provider is identified as an outlier or different vulnerabilities are identified with risk ratings, it is important to develop an audit and corrective action plan.

When a healthcare provider is alleged to have violated the law, OIG's first priority is to protect the U.S. Department of Health & Human Services' (HHS) programs and _________ Answers: a. the healthcare staff b. compliance office c. substantial money d. beneficiaries

Selected Answer: Correctd. beneficiaries Response Feedback: Beneficiaries. When a healthcare provider is alleged to have violated the law, OIG's first priority is to protect the U.S. Department of Health & Human Services' (HHS) programs and their beneficiaries.

Sarah, Compliance Officer for Apple Hospital , explains to the physicians on staff that _________ can occur when the same service is billed to Medicare and then billed to a private insurance company or to the patient. Answers: a. clustering b. abuse c. waste d. double billing

Selected Answer: Correctd. double billing Response Feedback: Double billing can occur when the same service is billed to Medicare and then billed to a private insurance company or to the patient. The OIG guidance states, "Although duplicate billing can occur due to simple error, the knowing submission of duplicate claims—which is sometimes evidenced by systematic or repeated double billing—can create liability under criminal, civil, and/or administrative law."

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. Answers: a. in the same town. b. available by telephone c. in the same exam room with him and the patient. d. in the same office suite

Selected Answer: Correctd. in the same office suite Response Feedback: The rules for incident-to billing- The provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is provided.

During an internal investigation, creating an audit report for negotiation is important. Overpayments (as well as underpayments) should be included as_________. Answers: a. revenue b. supporting documentation c. voluntary disclosure d. offsets

Selected Answer: Correctd. offsets Response Feedback: Creating an audit report for negotiation is important. Overpayments (as well as underpayments) should be included as offsets. These are allowed, and even specifically referenced, in Medicare manuals. The report should include a concise argument for the regulatory position you are taking with regard to coding, contracting, or manual provisions.

A provider at Apple Community Hospital asks the Compliance Officer if the Medicaid Integrity Contractor (MIC) has authority to audit claims in a particular region or in any state? The Compliance Officer states that _________ Answers: a. MIC's can only audit providers in the eastern part of the US. b. there are certain regions that the MIC's work within. c. the MIC's are assigned a specific section of the US. d. the MIC's can work in any state.

Selected Answer: Correctd. the MIC's can work in any state. Response Feedback: A MIC can audit a Medicaid provider throughout the country. The audits are intended to identify overpayments and inappropriate Medicaid claims. The auditors will look to see if the services were covered by Medicaid and billed and documented correctly. MICs can go to a provider's location or request records.

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

Selected Answer: a. Clinton Response Feedback: The Family Medical Leave Act (FMLA) was established in 1993 and officially signed by President Bill Clinton on February 5, 1993.

John, Compliance Officer for ABC Internal Medicine Group explains to the providers that even though they are a very small medical group that they still need to have designated parking for: Answers: a. at last 1 handicap accessible parking spot for either patient or employee. b. at least 2 patients and 1 employee spots. c. at least 3 patients and 2 employees spots. d. at least 1 patient and 1 employee spot.

Selected Answer: a. at last 1 handicap accessible parking spot for either patient or employee. Response Feedback: At last 1 handicap accessible parking spot for either patient or employee. If a physician practice or medical organization provides parking for the public, there must be handicap accessible parking spaces for cars and vans provided, if it is readily achievable to do so. One of every six spaces must be van accessible. Small businesses with very limited parking (four or fewer spaces) do not have to post signs; however, there must be one handicap accessible parking space for both disabled employees and patients. An accessible parking space must have an access aisle, which allows a person using a wheelchair or other mobility device to get in and out of the car or van.

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

Selected Answer: b. 1964 Response Feedback: The Civil Rights Act was implemented in 1964.

What goes together with compliance issues? Answers: a. Management b. Time off Policies c. Employee training d. Human Resources

Selected Answer: d. Human Resources Response Feedback: Often, employees' human resource concerns go hand-in-hand with compliance issues.

Kim, Compliance Officer at Apple Rural Health Center explains to a provider that Employment at Will means that the employee may: Answers: a. be fired if they are disabled. b. quit their job for any reason without notice. c. be fired if they are a transgender. d. be fired for any reason as long as it is not an illegal reason.

Selected Answer: d. be fired for any reason as long as it is not an illegal reason. Response Feedback: Be fired for any reason as long as it is not an illegal reason. The employment-at-will doctrine is a legal concept that means in the absence of employment contracts, including collective bargaining agreements, which would require reasons for termination, employers may fire employees for any reason, no reason, and even unfair reasons, as long as they are not illegal reasons.

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. Answers: a.Drug screens are often given to employees in healthcare. b.The employee is correct, it is discrimination. c.The employee is wrong. Employers can test at anytime for any reason. dDrug screens can be done on an employee if there is reasonable suspicion that the employee is impaired.

Selected Answer: d.Drug screens can be done on an employee if there is reasonable suspicion that the employee is impaired. Response Feedback: It is acceptable to perform pre-employment drug screens of employees as a condition of employment. In addition, a drug screen should be done on any employee when there is a reasonable suspicion that the employee is impaired. A drug screen also can be done if an employee is involved in an accident, or if the employee is involved in a recovery program.

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

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

What is an example of using the process of complete elimination or destruction of all forms of microbial life? Disinfection Sterilization Cleaning Using bleach

Sterilization Sterilization eliminates all forms of microbial life and is required for any instruments or objects that enter into human tissue.

Routine waiver of co-pays would be considered a violation of which law? The Anti-Kickback Statute Stark law False Claims Act HIPAA

The Anti-Kickback Statute Examples of anti-kickback statute violations include: • 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

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 The referring physician's best friend from medical school owns the entity receiving the referral The referring physician's neighbor owns the entity receiving the referral The referring physician's chiropractor owns the entity receiving the referral

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

When is an outside consultant and/or legal counsel necessary? Only when an overpayment is identiied. 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. in the beginning of plan development Never

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. There is no requirement that outside consultants or legal counsel be involved in a Compliance Program. However, during certain phases of program development and implementation, both consultants and legal counsel may be beneficial.

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: a. This would be considered unbundling and is illegal. b. This is considered a Stark Violation and is illegal. c. This is not a good idea because there might be a better CPT code that covers even more than what the provider documented. d. Good idea. We want the provider to get the most out of all billing opportunities.

a. This would be considered unbundling and is illegal. Billing several procedure codes when there is a more comprehensive code to report services is considered unbundling and can result in higher reimbursement

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. a. Training and Education b. Keeping the floors clean c. HR Screening d. Drug Testing

a. Training and Education Training and Education. OSHA believes education and assistance to employers is key to their mission and to the safety of employees.

Anti-dumping statues, 42 U.S.C. 1395dd, require a hospital to do all of the following except? a. Transfer to another hospital if emergency room is busy b. Provide a medical screening examination c. Stabilize any condition the patient might have d. Do medical screening when requested by patient to see if they have a medical emergency.

a. Transfer to another hospital if emergency room is busy The statute requires all hospitals that participate with Medicare follow the patient dumping rules. There are strict rules about what must be done before a patient can be transferred.

When would an employer need to complete an OSHA 300 form? a. When there is a work-related contaminated needle stick or sharps injury b. When someone working there has an accident c. When someone working there has an injury d. When someone working there gets cut by a sharp object

a. When there is a work-related contaminated needle stick or sharps injury You must record all work-related needle stick injuries and cuts from sharp objects that are contaminated with another person's blood or other potentially infectious material (as defined by 29 CFR 1910.1030). You must enter the case on the OSHA 300 Log as an injury.

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

a. With personal knowledge of the claim. Qui tam action is a powerful weapon against healthcare fraud because a private party with independent knowledge of wrongdoing may initiate the action.

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

a. Yes, even if remuneration is involved If the marketing involves direct or indirect remuneration to the covered entity from a third party, the authorization must state that such remuneration is involved.

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: a. Yes, if there is a Subpoena. b. No, not unless there is a signed consent by the patient. c. No, not unless the patient stipulated such action in his/her original statement to the office. d. Yes, if an attorney signs the release then the information can be released.

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

Tim at XYZ Billing wants to know if a billing company's Compliance Officer should work with the provider offices? a. Yes, the OIG recommends this action b. No, the OIG does not recommend this action c. Yes, as long as a BAA is signed d. No, all Compliance Officers need to keep their information confidential

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

Can the government take back money from a nursing facility for failure of patient care? a. Yes, there is a direct link to quality of care and billing for services b. No, it is not considered a false claim c. Yes, because the government can take back monies regardless of proof d. No, quality of care and billing are different

a. Yes, there is a direct link to quality of care and billing for services In cases that involve failure of care on a systemic and widespread basis, the nursing facility may be liable for submitting false claims for reimbursement to the Government under the Federal False Claims Act, the Civil Monetary Penalties Law (CMPL), or other authorities that address false and fraudulent claims or statements made to the Government.

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: a. 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 b. No, next of kin needs to be located first. c. No - All PHI is protected, under any circumstance. d. Yes- If the person normally goes to that hospital pharmacy.

a. 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

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? a. compliance officer b. internal certified coders c. consultant d. billing manager

a. compliance officer In a prospective audit, a designated individual (such as the CO or a designee) reviews claims before they are submitted to the payer to ensure the appropriateness of the coding and documentation, and adherence to health plan medical payment policies.

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) a. to inform the healthcare industry and general public of how and where to report information about suspected fraudulent and abusive practices b. to inform the providers how to protect themselves c. to inform CEOs so that they will know how to plan accordingly d. to inform the abusers of the plan so that it is not considered entrapment

a. to inform the healthcare industry and general public of how and where to report information about suspected fraudulent and abusive practices The OIG and [CMS] periodically issue fraud alerts setting forth activities believed to raise legal and enforcement issues.

Urine dipsticks and finger-stick blood tests performed in a physician's office are subject the office to CLIA regulations. These are called _________ a. waived tests b. simple tests c. exempt tests d. easy tests

a. waived tests Waived tests. Tests that are categorized by the federal CLIA as waived may be categorized by a state DOH/CLIA as moderate. Waived tests, which are simple tests with little chance of error, are exempt from most of the CLIA rules required by more complex laboratories as long as the tests are performed in accordance with the manufacturer's instructions. A facility only doing blood draws or urine collection (for outside testing) are not performing tests and are not subject to the CLIA regulations.

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

a. waived, moderate-microscopy (PPM), and high complexity The final CLIA regulations were published on February 28, 1992 and are based on the complexity of the test method; thus, the more complicated the test, the more stringent the requirements. Three categories of tests have been established: waived complexity, moderate complexity, including the subcategory of provider-performed microscopy (PPM), and high complexity.

Joan, Compliance Officer at XYZ Hospital, explains to the hospital board that in 2003 a provision was added to EMTALA that stated that there is a _____yard zone that continues to apply when defining the hospital campus. a.250 b.200

a.250 In 2003, a provision was added to clarify when/where EMTALA applies That there is a 250-yard zone that continues to apply when defining the "hospital campus." That sphere does not include non-medical businesses (shops and restaurants located close to the hospital), nor does it include physicians' offices or other medical entities that have a separate Medicare identity.

Having open and frequent communication with _____________ of their mandatory responsibility to refund monies that are found to be overpayment with documentation of this process is fundamental to a medical billing company. a.Health care providers b.Federal government c.Clearing houses d.Local government

a.Health care providers The OIG believes that open and frequent communication between the medical billing company and their health care providers is fundamental to the success of any compliance endeavor. OIG states that billing companies play a critical role in the restitution of overpayments to appropriate payers. This is mainly in the form of identification and communication with the providers of their mandatory responsibility to refund monies that are found to be overpayment or not otherwise the property of the provider. Documentation of this process is imperative to the billing company.

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: a.No- certain notes such as psychotherapy notes cannot be released. b.No- only if the patient pays up front for the copies. c.Yes- if the patient is over the age of 21 and of sound mind. d.Yes- as long as there is a signed release form that is recent (within the last 12 months.)

a.No- certain notes such as psychotherapy notes cannot be released. No- certain notes such as psychotherapy notes cannot be released. Psychotherapy notes have more stringent restrictions that require patient consent, except for malpractice or serious and imminent threat to safety, or as required by law.

A pertinent component of an effective Compliance Program includes _______________? a.Training and educating employees b.Credentialing providers on a timely basis c.Meeting deadlines d.Reporting all suspected fraud to HHS immediately

a.Training and educating employees OIG recommends that all employees be trained and educated in the parts of the compliance program that effects that employee. It also, states that training should be updated at least once a year there after.

The Compliance Officer's main two responsibilities are to ____________the practice/organization's compliance program. Selected Answer: a.develop and then implement b.write and oversee c.report to the board and CFO d.provide training and policies for

a.develop and then implement The Compliance Officer's main two responsibilities are to develop and then implement the practice/organization's compliance program.

The 250-yard zone rule does not apply to: all hospital-owned physician practices the main entrance of the hospital the emergency department the parking lot

all hospital-owned physician practices The 250-yard zone applies when defining the "hospital campus." That sphere does not include non-medical businesses (shops and restaurants located close to the hospital), nor does it include physicians' offices or other medical entities that have a separate Medicare identity.

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

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

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? a. Kelly should train all the coders and billers to know the billing rules for Medicaid and Nurse Practitioners for all the specialties. b. Kelly should give specialized training to the 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. c. These are not issues at all. Compliance and training will not be affected.

b. Kelly should give specialized training to the coders and billers that code/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. Specialized compliance training is sometimes required. In some large provider groups there are often different types of specialties.

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? a. Nursing Facilities b. Medical Billing Companies c. Clinical Laboratories d. Consultants

b. Medical Billing Companies Providers have come to rely heavily on medical billing companies to submit their claims correctly.

What can result in imprisonment and penalties for providers and covered entities? a. Abuse of the federal and state government without intent b. Medical fraud c. Abuse of the state government without intent d. Abuse of the federal government without intent

b. Medical fraud Medical fraud is a federal crime that is costly and, when committed, can result in financial penalties and jail time. The difference between fraud and abuse is "intent."

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

b. Monitoring Audits are performed based on specific guidelines or concerns. Monitoring is ongoing spot checks to identify any potential risk areas.

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

b. No, EMTALA does not include physician practices. In 2003, a provision was added to clarify when EMTALA applies, as follows: A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA. Other presentations outside the emergency room do not invoke EMTALA. • The 250-yard zone will continue to apply when defining the "hospital campus." Now, however, that sphere does not include non-medical businesses (shops and restaurants located close to the hospital), nor does it include physicians' offices or other medical entities that have a separate Medicare identity. • EMTALA does not apply to any off-campus facility, regardless of its provider-based status, unless it independently qualifies as a dedicated emergency department.

Sam is the Compliance Officer for MNO Internal Medicine Group. MNA has just signed a Compliance Certification Agreement (CCA). Sam is unsure if an Independent Review Organization (IRO) is required with the CCA. What is the correct answer below? a. No, an IRO is only required for certain entity's that have signed a CCA b. No, an IRO is not required while an entity has a CCA c. Yes, an IRO is required for all CCA agreements d. Yes, IRO's are required for both CIA and CCA arrangements

b. No, an IRO is not required while an entity has a CCA Certificate of Compliance Agreements (CCA) is for 3 years and does not require an IRO. CIA is for 5 years and requires an IRO.

Larry is the coder / biller at Orange Medical Group. He is afraid that if he makes a simple mistake he will be fined under the False Claims Act. Is Larry's concerns valid? a. Yes. Larry would be held accountable under the False Claims Act. b. No. Larry needs to know the laws, but if a mistake is made and then corrected, he will not be fined under the False Claims Act. c. No. Larry is only accountable under the Stark Laws. d. Yes, Larry needs to know the law and follow them because he could be fined if he makes any mistakes.

b. No. Larry needs to know the laws, but if a mistake is made and then corrected, he will not be fined under the False Claims Act. The Civil Monetary Penalty Law and the False Claims Act (FCA)—are related to proper claims filing. Mere mistakes, which can be remedied by returning overpayments, do not result in violations of these laws.

The OIG recommends that each Compliance Program should be______________? a. Developed by an attorney b. Unique c. Comprehensive d. HIPAA and OSHA only

b. Unique Because each organization is unique, each Compliance Program should be developed to enhance and protect the individual entity.

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? a. United Sates Sentencing Committee b. United States Sentencing Commission c. United States Security Committee d. United States Security Commission

b. United States Sentencing Commission

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

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

What Federal department will consider self-reporting of misconduct as a mitigating factor? a. Center for Medicare & Medicaid Services (CMS) b. Office of Inspector General (OIG) c. Health Enforcement Action Team (HEAT)) d. Department of Justice (DOJ)

b. Office of Inspector General (OIG) The OIG considers the self-reporting of misconduct a mitigating factor in determining administrative sanctions, if the reporting company becomes the target of an OIG investigation.

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: a. Location of the Hospital, Room Number and General Condition of the Patient. b. Patient Name, Location of Facility and General 1-word statement about the condition of the patient. c. Patient Name, Location of the Hospital and Phone Number to the patient room d. Nothing can be said to the general public with a release of information statement.

b. Patient Name, Location of Facility and General 1-word statement about the condition of the patient. Patient Name, Location of Facility and General 1-word statement about the condition of the patient is the only information that is allowed to be given out without a signed release form

What safeguard is defined as measures to protect electronic systems? a. Administrative safeguards b. Physical safeguards c. Technical safeguards d. Facility safeguards

b. Physical safeguards Physical safeguards are defined as measures to protect a covered entity's electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion.

What is the routine cleaning guidelines for BP cuffs? a. Clean cuffs daily with Sani-wipe b. Provide disposable cuffs to all isolation patients c. Clean cuffs weekly with alcohol d. Clean cuffs weekly with diluted bleach

b. Provide disposable cuffs to all isolation patients The guideline requires that medical facilities provide disposable blood pressure cuffs to all isolation patients.

Federal regulations pertinent to billing companies include all except: a. Patient Protection and Affordable Care Act (PPACA) or (ACA); or Healthcare Reform; or Obamacare b. Safe Harbor Rules for Billing Companies c. False Claims Act (FCA) d. Health Insurance Portability and Accountability Act (HIPAA)

b. Safe Harbor Rules for Billing Companies The "safe harbor" regulations describe various payment and business practices that, although they potentially implicate the Federal anti-kickback statute, are not treated as offenses under the statue.

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? a. Three b. Seven c. Six d. Five

b. Seven The OIG has stated, based off of their audit results, that seven components are key factors in having an effective compliance program.

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. a. Anti- Kickback b. Special Fraud Alert c. Code Alert d. Stark Law

b. Special Fraud Alert The OIG has designed and issued special fraud alerts to the health care provider community for the last 20 years.

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? a. Do not allow the employee to provide services to government program patients b. Suspend the employee, request documentation, and investigate the matter. c. Terminate them immediately and refund the government payer. d. Do not allow the employee to provide services and remove their salary from the Medicare cost report.

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

A Relator is the: Selected Answer: Correctb. The Whistleblower Answers: a. The OIG agent that intervenes. b. The Whistleblower c. The Provider who makes the complaint. d. Hospital where the complaint is made.

b. The Whistleblower Civil actions may be brought in federal district court under the FCA by the attorney general, or by a relator (whistleblower), in a qui tam action.

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

b. The authorization should have a right to revoke and should have an expiration All authorizations to disclose PHI need to have an expiration date and provide an avenue for the patient to revoke his or her authorization.

CLIA is funded by whom? a. CMS b. Users c. MACs d. Patients

b. Users CLIA is user fee funded; therefore, all costs of administering the program must be covered by the regulated facilities.

Tim is the Compliance Officer for Community Hospital. Tim understands that having an effective compliance program will help to speed and optimize proper payment of claims and billing mistakes. It will help protect patient privacy and reduce chances of an audit. It will also help avoid minimizes billing mistakes conflicts of interest and helps to comply with the self-referral and anti-kickback statutes. These are all ___________ of having a compliance program. a. voluntary components b. benefits c. elements d. mandatory requirements

b. benefits There are many benefits of implementing a well-designed compliance program. It will help to speed and optimize proper payment of claims and billing mistakes. It will help protect patient privacy and reduce chances of an audit. It will also help avoid minimizes billing mistakes conflicts of interest and helps to comply with the self-referral and anti-kickback statutes

Joan, Compliance Officer for XYZ Hospital explains to the Medical Staff that physicians can be fined / penalized if they fail to respond to an emergency situation if they are on call. It is a good idea that the hospital develops an ____________: a. community assist program b. community call program. c. community help line d. community hot line

b. community call program. Community call program In September 2003, HHS clarified that on-call physicians may have simultaneous on-call duties and schedule elective surgery during the time that they are on-call. (68 FR 53,264 (Sept. 9, 2003)). In its most recent revision to the federal regulations, HHS agreed to allow hospitals to satisfy their on-call coverage obligations by organizing an approved community call/regional call program. (73 FR 48,434, 48,662 (Aug. 19, 2008)). The community call plans are not subject to local, state or federal pre-approval; however, CMS has identified certain elements that must be part of a formal community call plan, if one is adopted. (42 CFR § 489.24(j)(2)(iii)).

The hospital that John works for was just issued a CIA. What is the typical term of a CIA that John can expect for the hospital that he works for? a. three years b. five years c. seven years d. one year

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

Waived and PPM laboratories may apply directly for their certificate as they are not subject to_________________? a. sanctions b. routine inspections c. surveys d. waiting periods

b. routine inspections Waived and PPM laboratories may apply directly for their certificate as they aren't subject to routine inspections. Those laboratories that must be surveyed routinely; i.e., those performing moderate and/or high complexity testing, can choose whether they wish to be surveyed by HCFA or by a private accrediting organization.

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____: a. this cannot happen because it is already locked after 5 pm every day. b. this cannot happen because the exit door must always be kept unlocked c. this is a good idea as long as the employees know in advance. d. this is a good idea if they change the time from 2 am to 1 am once in a while to keep employees alert.

b. this cannot happen because the exit door must always be kept unlocked This cannot happen because the exit door must always be kept unlocked. An exit door must be unlocked. · Employees must be able to open an exit route door from the inside at all times without keys, tools, or special knowledge. A device such as a panic bar that locks only from the outside is permitted on exit discharge doors. · Exit route doors must be free of any device or alarm that could restrict emergency use of the exit route if the device or alarm fails. · An exit route door may be locked from the inside only in mental, penal, or correctional facilities and then only if supervisory personnel are continuously on duty and the employer has a plan to remove occupants from the facility during an emergency.

Dr. Smith asks you, the Compliance Officer, what is the typical term of a CCA? a. seven years b. three years c. one year d. five years

b. three years Certification of Compliance Agreements (CCAs), rather than more extensive CIAs. CCAs require providers to certify that they will continue to operate their existing compliance programs for a fixed term, typically 3 years, rather than enter into a more extensive CIA with a 5-year term. CCAs do not require independent review organizations to conduct or verify audits or claims reviews.

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

b.Proficiency testing (PT) CLIA specifies quality standards for proficiency testing (PT), patient test management, quality control, personnel qualifications and quality assurance, as applicable. Because problems in cytology laboratories were the impetus for CLIA, there are also specific cytology requirements.

Key risk areas defined for third-party medical billing companies for the OIG Compliance Program Guidance include all listed except: a.Unbundling b.Provider's signature c.Inappropriate balance billing d.Up-coding

b.Provider's signature Provider's signature is not a risk area for a third-party medical billing companies .

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? a.No, because Federal wire fraud does not apply to Medicare claims. b.Yes, because false claims were submitted electronically across state lines. c.Yes, because false claims were submitted. d.No, because multiple provider groups must be involved for Federal wire fraud to apply.

b.Yes, because false claims were submitted electronically across state lines. Federal wire fraud (18 USC 1343) covers any criminal fraudu¬lent activity that is determined to involve electronic communi¬cations of any kind. The citation specifically states: "Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, trans¬mits or causes to be transmitted by means of wire, radio, or television communication in interstate or foreign commerce, any writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or artifice, shall be fined under this title or imprisoned not more than 20 years, or both." This type of fraud involves such activities as transmitting claims for reimbursement through the Internet or Facsimile. It can also include telephone solicitation when fraud is the objec¬tive such as in the case of Medicare Parts C and D programs, supplemental insurance plans, private insurance programs, and DME solicitation. Fraudulent claims submitted electroni¬cally across state lines or internationally have the potential to be in violation of this statute.

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. A "quality first" b. A "privacy first" c. A "patients first" d. A "safety first"

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

Which of the following is not an example of safety measures? a. All employees will need to be trained and educated on safety b. Maintaining a safe environment of care should be an essential part of your organizations mission and strategy c. A security alarm system with same access ID for everyone d. Practice Managers and physicians should be sanctioned for safety and key role models in preventing injuries/illnesses

c. A security alarm system with same access ID for everyone When installing a security alarm system, it is important that everyone has a different access ID to be able to track who is entering and leaving the medical facility.

Joan is the Compliance Officer for XYZ Community Hospital. She gives OSHA Blood Borne Pathogens training to all of the following groups of people: a. All paid workers at XYZ that might come into contact with Blood Borne Pathogens. b. All Healthcare Workers at XYZ c. All paid and non-paid workers at XYZ that might come into contact with Blood Borne Pathogens. d. Only the nurses and physicians at XYZ

c. All paid and non-paid workers at XYZ that might come into contact with Blood Borne Pathogens. All paid and non-paid workers at XYZ that might come into contact with Blood Borne Pathogens. OSHA defines the term healthcare worker as all the paid and unpaid persons working in the healthcare setting who have the potential for bloodborne pathogens exposure. It is just as important to train students and volunteers on OSHA as it is your own employees.

The first responsibility of the Compliance Officer is the development of the Compliance Program. What is the first step in the process that needs to be completed before the formal Compliance Program documents are to be drafted? a. Policies and procedures should be developed b. Conduct a HIPAA and OSHA audit c. Areas of risk need to be assessed d. Training and education should be conducted

c. Areas of risk need to be assessed The first responsibility of the Compliance Officer is the development of the Compliance Program. As a first step in the process, areas of risk need to be assessed within the organization and then the formal Compliance Program documents need to be drafted. (Remember, if there is a Compliance Committee, the Compliance Officer will be the person to make sure that these tasks have been completed, either by the Compliance Officer himself/herself or by members of the committee)

Which certificate is issued to a laboratory that enables the entity to conduct moderate or high complexity laboratory testing or both until the entity is determined by survey to be in compliance with the CLIA regulations a. Certificate of Compliance b. Certificate of Waiver c. Certificate of Registration d. Certificate of Accreditation

c. Certificate of Registration Certificate of Registration-This certificate is issued to a laboratory that enables the entity to conduct moderate or high complexity laboratory testing or both until the entity is determined by survey to be in compliance with the CLIA regulations.

John, Compliance Officer at ABC Internal Medicine Group, explains to the front office staff that release of information authorizations must: a. Contain two signatures (patient and witness.) b. Contain two signatures (patient and 1 office staff.) c. Contain an expiration date and a statement regarding right to revoke. d. Contain social security information.

c. Contain an expiration date and a statement regarding right to revoke. Contain an expiration date and a statement regarding right to revoke. An authorization must be written in plain language with specific terms, and can allow the disclosure of PHI by the entity seeking authorization. Authorizations are necessary for all uses and disclosures not described above (for example, third-party employers or life insurers.) The authorization must contain an expiration date and a statement regarding right to revoke (in writing) the authorization at any time.

During the New Hire Orientation, John - Compliance Officer- explained that EMTALA came about because some hospitals / physicians at the hospitals were: a. Disregarding patients b. Hurting patients c. Dumping patients d. Ignoring patients

c. Dumping patients Dumping patients. Congress enacted EMTALA in response to increasing concerns that hospitals were denying emergency care to indigent and uninsured patients, and "dumping" them to another facility for care (usually "charity" or "county" hospitals), or to no facility at all, by discharging the patient after a token, inadequate medical exam. In essence, EMTALA is a non-discrimination statute.

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

c. EMTALA A physician who is on call and who fails or refuses to appear after being called by another physician to the ER may be subject to a penalty under the statute, or may subject his hospital to a penalty [1395dd(d)(1)(C)] (EMTALA)

The OIG Five Principal Strategy is made up of the following: a. Enrollment, Payment, Compliance, Audits and Response b. Enrollment, Fines, Compliance, Oversight and Response c. Enrollment, Payment, Compliance, Oversight and Response d. Enrollment Payment, Compliance, Oversight and Audits

c. Enrollment, Payment, Compliance, Oversight and Response The Five Principal strategy was originally recommended in 1990, but became a reality in June 2009 to provide the framework to identify new ways to protect the integrity of the programs and keep Federal healthcare programs solvent for future generations.

When a hospital sends a patient home, or transfers the patient, without providing care us called what? a. Home discharge b. Referral c. Patient dumping d. Inappropriate discharge

c. Patient dumping As part of the Consolidated Omnibus Reconciliation Act of 1985 (COBRA), Congress addressed the problem of patient dumping by way of the Emergency Medical Treatment and Active Labor Act (EMTALA). Patient dumping is when a hospital sends a patient home, or transfers the patient, without providing care. EMTALA requires that Medicare-participating hospitals provide to any patient who comes to the emergency department, at least a medical screening exam to see if an emergency medical condition exists.

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: a. FCA, AKS, Stark, CMPL, OIG b. Stark, AKS, Exclusion, FCA, OIG c. FCA, AKS, Stark, Exclusion, CMPL d. ACA, OIG, CMS, ACO, FCA

c. FCA, AKS, Stark, Exclusion, CMPL The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws.

Clinical Laboratories should charge physicians a price for ordered tests at ____________________________. a. Huge cost savings b. Special pricing c. Fair market value d. Lower than market value

c. Fair market value In order to not be in violation of Anti-Kickback rules clinical laboratories will need to charge all providers referring to them fair market value pricing.

Kim, the Compliance Officer at Apple Rural Health Center, must report the OSHA incidents on Form 301 every year between the months of ________: a. Jan - March 30th b. March -May 30th c. Feb-April 30th d. April - June 30th

c. Feb-April 30th Incidents that are recorded maintained by the employer on the OSHA 300 form and then appropriate information transferred to the OSHA 301 form for posting from February 1 to April 30, each year.

SNF best practice guidelines would have the CO doing which of the following? a. Only pull a report of your levels of therapy denied b. Determine your lowest therapies billed c. If audit determines claims did not meet medical necessity you should report to CMS within 60 days d. All of the above

c. If audit determines claims did not meet medical necessity you should report to CMS within 60 days The best practice guidelines a CO should do of an SNF is if the audit determines claims did not meet medical necessity you should report to CMS within 60 days

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? a. Review dates b. The compliance officer c. Implementation d. The Policy Library

c. Implementation Implementation is the most important aspect of a Compliance Program.

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

c. No requirement OSHA regulations do not specify or require employers to display the OSHA poster in a foreign language.

Can an individual provide a verbal authorization to release PHI? a. Yes, in certain states b. Yes, in the state of California c. No, all authorizations must be in writing d. Yes, only in New York

c. No, all authorizations must be in writing All valid authorizations for disclosure must be in writing.

Which component of the OIG has a duty of conducting audits, which result in reducing waste, abuse, and mismanagement? a. Office of Management & Policy b. Office of Evaluations & Inspections c. Office of Audit Services d. Office of Investigations

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

Jill works for ABC Family Practice. Jill wants to find out more about the HIPAA Privacy Rule and Security Rule provisions. Which office or department would Jill contact? a. Department of Justice (DOJ) b. Office of Inspector General (OIG) c. Office of Civil Rights (OCR) d. Department of Labor (DOL)

c. Office of Civil Rights (OCR) The OCR is responsible for enforcing the HIPAA Privacy Rule and Security Rule provisions. It also oversees the provisions of the Civil Rights Act of 1964 as it applies to Limited English Proficiency (see below), the confidentiality provisions of the Patient Safety Act and Rule, and the Church Amendments, section 245 of the Public Health Service Act, and the Weldon Amendment, collectively known as the Federal Health Care Provider Conscience Protection Laws.

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: a. Centers for Medicare & Medicaid Services b. Immediate Office of the Inspector General c. Office of Inspector General d. Office on Auditing

c. Office of Inspector General The OIG has been providing compliance program guidelines since 1998.

Which government branch was created to fight waste, fraud and abuse in all federal health care programs especially Medicare, Medicaid? a. Department of Health & Human Services (HHS) b. Department of Justice (DOJ) c. Office of Inspector General (OIG) d. Office for Civil Rights (OCR)

c. Office of Inspector General (OIG) The Office of Inspector General conducts independent audits, inspections, and investigations in all federal health care programs.

The Compliance Officer is also responsible for the coordinating and/or screening of employees, agents and independent contractors. Why is this important? a. Organizations cannot do business with individuals who are delinquent in child support payments b. Organizations cannot do business with individuals who have filed bankruptcy c. Organizations cannot do business with individuals who have been excluded from participating in federally funded healthcare plans d. Organizations cannot do business with individuals who have open tax liens

c. Organizations cannot do business with individuals who have been excluded from participating in federally funded healthcare plans The Compliance Officer is also responsible for the coordinating and/or screening of employees, agents and independent contractors. This will involve making inquiries to the Cumulative Sanction Report and the GSA debarred contractors listing. As specified in the Code of Conduct, no employee or agent of the 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.

Which law increases the severity of penalties for violations involving organized crime? a. DEFRA b. FERA c. RICO Act d. MMA

c. RICO Act The RICO Act is a law that increases the severity of penalties for violations involving organized crime.

What were the target of Physician at Teaching Hospitals (PATH) audits? a. medical necessity of services performed and documentation for level of service provided b. medical necessity of services performed and incident-to guidelines c. documentation of physician involvement in services that were performed or present when a resident provided the service with documentation supporting the level d. physician oversight of residents and incident-to guidelines

c. documentation of physician involvement in services that were performed or present when a resident provided the service with documentation supporting the level The PATH audits targeted insufficient medical record documentation to support whether a physician either performed the service or was present when a resident performed the service. As a result of findings in the CPUP audit, insufficient documentation supporting the level of service was also targeted.

The Medicare Modernization Act (MMA) of 2003 gave momentum to what movement? a. Quality movement b. Electronic health record movement c. e-prescribing movement d. Whistleblower movement

c. e-prescribing movement The Medicare Modernization Act (MMA) of 2003 gave momentum to the e-prescribing movement, and was put in place to reduce medication errors due to illegible physician handwriting, etc. Adopting the standards to facilitate e-prescribing is one of the key action items in the government's plan to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States.

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

c. exclusion from Medicare Physicians who negligently violate EMTALA are subject to civil monetary penalties and for repeated or gross and flagrant violations, exclusion from Medicare.

Hospitals need to post signs of a patient's EMTALA rights. The signs must meet certain requirements regarding __ and _____________. a. EMTALA specific rules and state sites to visit. b. which insurance they take and which ones they do not c. language and readability d. which hospitals participate and which ones do not.

c. language and readability Language and readability. Hospitals need to post signs of a patient's EMTALA rights. The signs must meet certain requirements regarding language and readability.

Requirements for transferring an unstable patient include all but a. physician must attest the medical benefits outweigh the risk of the transfer in writing b. consent of the receiving hospital c. making sure patient has either Medicare or Medicaid d. patient's consent must be documented

c. making sure patient has either Medicare or Medicaid Insurance can never be a reason for either treatment or transferring of patients. Under EMTALA all individual must be treated regardless of ability to pay.

What is more important to have in place for enforcing and disciplining individuals who violate the practice's compliance or other practice standards? a. meetings b. training c. procedures d. rules

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

Circumnavigation schemes can occur when a physician or other entity enters into an arrangement that the entity /physician knows that ____________will occur. a. gifts b. patient transfers c. referrals d. payments

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

Everyone should be educated in their role in adhering to the Compliance Program including their duty to report__________________? a. employees who are chronically late b. safety issues c. suspected misconduct d. quality issues

c. suspected misconduct Everyone should be educated in their role in adhering to the Compliance Program including their duty to report misconduct, the procedures and methods to report suspected misconduct, confidentiality and when/where confidentiality ends, as well as the organization's non-retaliation policy for good faith reporting

Failure to respond quickly to suspected or alleged instances of non-compliance threatens the organization's reputation as trustworthy, law-abiding, and ______________? a. the organization's ability to accept cash patients. b. the organization's ability to scrutinize practices for other providers. c. the organization's ability to participate with federally funded healthcare plans and/or third party payers. d. the organization's ability to hire new employees.

c. the organization's ability to participate with federally funded healthcare plans and/or third party payers. Non-compliance with the Corporate Compliance Program and all applicable laws and regulation threatens the organization's reputation as a trustworthy, law-abiding organization and threatens the organization's ability to participate with federally funded healthcare plans and/or third party payers. It is for these reasons that the Compliance Program has been developed and why responding quickly to suspect or alleged instances of non-compliance is imperative.

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

c.HHS Rationale: The FDA has broken down the tasks performed by the three federal agencies responsible for CLIA: FDA, CMS, and CDC. Each agency has a unique role in assuring quality laboratory testing

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

c.Pregnant patient comes into the ER having contractions. Rationale: EMTALA applies to hospitals, not physician's offices. EMTALA defines an emergency medical condition that it is at a sufficient severity that the absence of immediate medical attention could result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ part. EMTALA also defines an emergency medical condition to include a pregnant woman who is having contractions.

Under the anti-kickback statute, it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal healthcare program. This would include all of the following: a. a referral b. Money c. Gift d. All of the above

d. All of the above Under the Anti-Kickback Statute (AKS), it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value (remuneration) in return for a referral, or to induce generation of business reimbursable under a federal healthcare program. The statute prohibits both the offer or payment of remuneration for patient referrals, and the offer or payment of anything of value in return for purchasing, leasing, ordering, arranging for, or recommending the purchase, lease, or ordering of any item or service that is reimbursable by a federal healthcare program.

Which ACT is not overseen by the Department of Labor? a. Fair Labor Standards Act (FLSA) b. Employee Retirement and Income Safety Act (ERISA) c. Occupational Safety and Health Act (OSHA) d. Clinical Laboratory Improvement Amendments (CLIA)

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

Every third party health care company should designate someone to serve as the focal point for compliance activities. This position is called a ________________________. a. Physician b. Compliance Coordinator c. Practice Administrator d. Compliance Officer

d. Compliance Officer The Compliance Officer (CO) needs to be someone who has the support of the upper management and who can enforce actions to make sure that the compliance program is being handle correctly. The CO should also be someone who is approachable for employees to come to when a problem occurs and know that they will not be punished for doing so.

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

d. Create all policies and procedures A Compliance Officer can ensure that policies and procedures are in place. However, it is not his or her responsibility to create them.

The DOJ's current strategic plan does NOT include the following overarching goals: a. Ensure and support the fair, impartial, efficient, and transparent administration of justice at the federal, state, local, tribal, and international levels. b. Prevent terrorism and promote the nation's security consistent with the rule of law. c. Prevent crime, protect the rights of the American people, and enforce federal law. d. Decrease the spread of disease by working with the Center for Disease Control (CDC).

d. Decrease the spread of disease by working with the Center for Disease Control (CDC). The FBI and DEA are part of the DOJ that work together to fight terrorism, crime, and promote justice. The DOJ is not part of the CDC.

What is not included in the Hazard Communication Standard? a. A list of hazardous chemicals (such as alcohol, disinfectants, anesthetic agents, sterilants, and mercury) used or stored in the office b. A written hazard communication program c. A copy of the Material Safety Data Sheet (MSDS) for each chemical (obtained from the manufacturer) used or stored in the office d. Employee training on evacuation routes

d. Employee training on evacuation routes The hazard communication standard is sometimes called the "employee right-to-know" standard. It requires employee access to hazard information, which does not include evacuation routes.

Employers are required to maintain an equipment injury log that includes all but_______? a. The type and brand of device involved in an accident b. Location of the incident c. Description of the incident d. Employee's name involved with the device accident

d. Employee's name involved with the device accident All information should be de-identified, which means that the employee's name would not be included on the log.

How did HIPAA change health care? a. It made employees more accountable. b. It changed medical authorization forms. c. It helped create electronic health record templates. d. It improved efficiency of the health care system

d. It improved efficiency of the health care system The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191 improved efficiency and effectiveness of the health care system.

John is the Compliance Officer for a small hospital. He has been in compliance for a few years. What must John know and understand for his job title? a. John should also consider going to law school so he can also act as legal counsel to the hospital. b. John must memorize as many compliance facts as possible so that he can protect the hospital. c. John should ask the OIG for a meeting to discuss compliance and assist him with understanding all the rules and regulations that he must memorize. d. John should get a compliance credential and continue to learn to grow as a compliance professional and know/understand where to look for compliance resources.

d. John should get a compliance credential and continue to learn to grow as a compliance professional and know/understand where to look for compliance resources. A compliance program addresses the ever growing requirements of the various laws, regulations, rules and guidelines. The ACA mandated compliance in 2010, part of which is a Compliance Officer or Compliance Point of Contact.

What is (are) considered a significant element(s) in fraud? a. Using the Compliance Guidance as a guide for your practice b. Reviewing OIG Exclusions c. Billing for services performed d. Knowingly and Intent

d. Knowingly and Intent Under HIPAA, fraud is defined as "knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program." The difference between fraud and abuse is the individual's intent.

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

d. Upon hire and every year. Frequency of TB testing for HCW depends on risk factors and State Guidelines- per the CDC Appendix C- Prevention. Low Risk- only on hiring and as needed. Medium Risk- annually and as needed.

Joan is one of the coders/billers at XYZ Family Practice Office. She tells her husband that she thinks XYZ is committing fraud. He advises her to discuss this with her supervisor. After she leaves for work, he calls an attorney to tell him about the issue and to file a Qui Tam. It is likely the attorney will say: a. Good, I am glad you are honest. b. Let's start the process of the Qui Tam and then your wife can fill in the other information. We need to start this now before any other person makes a claim. c. No, I cannot work with you because only the Compliance Officer can make such accusations. d. Sorry, but you do not have firsthand / actual knowledge of the facts.

d. Sorry, but you do not have firsthand / actual knowledge of the facts. Civil actions may be brought in federal district court under the FCA by the attorney general, or by a relator (whistleblower), in a qui tam action. Qui tam action is a powerful weapon against healthcare fraud because a private party with independent knowledge of wrongdoing may initiate the action. FCA recoveries fund government programs and are a big part of paying for health reform.

Records associated with an inquiry will include the nature of the inquiry or report, the investigation procedures and outcomes, and all actions taken by the Compliance Officer and/or the organization to rectify any non-compliance uncovered. What is an important component of the compliance officers responsibly when managing incidents and investigations? a. CMS needs to be kept apprised of ongoing investigations and results b. The staff needs to be kept apprised of ongoing investigations and results c. The OIG needs to be kept apprised of ongoing investigations and results d. The Board of Directors need to be kept apprised of ongoing investigations and results

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

When the term Open Door Policy is used in reference to the Effective Communication, what is this referring to? a. Only the physicians can have access to the Compliance Officer b. The Compliance Office must always leave his/her door open c. The Compliance Officer will only be able to effectively communicate in the office with the door open d. The Compliance Officer is accessible to all employees via many methods of communication

d. The Compliance Officer is accessible to all employees via many methods of communication The OIG recommends an "open door" policy between the physicians and compliance personnel and practice employees. This policy can be implemented with less formal communication techniques, such as conspicuous notices posted in common areas and/or the development of compliance bulletin board, etc. Many various options when using an "open door" policy.

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

d. The Privacy Rule The Privacy Rule defines and limits the circumstances in which an individual's protected heath information (PHI) may be used or disclosed by "covered entities"

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

d. To ensure proper employee protection measures To reduce or eliminate the hazards of occupational exposure, an employer must implement an exposure control plan for the worksite with details on employee protection measures.

When can PHI not be disclosed without a patient's consent? a. When immediate action is required to save patient's life b. Emergency situations c. When it can prevent permanent damage to the patient d. To let your brother know his neighbor may have a contagious disease.

d. To let your brother know his neighbor may have a contagious disease. PHI can be disclosed in emergency situations, when immediate action is required to save the patient's life, or to prevent permanent damage to the patient's life, or to prevent permanent damage to the patient's health.

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 is: a. No information is needed. The person is just to get immediate treatment and follow rules so the incident does not happen again. b. Name of the patient; Medical Record of the patient; Recent labs of the patient c. Name of supervisor so that a written warning can be issued to protect the employer. d. Type and brand of device involved in the incident; location of incident; description of incident

d. Type and brand of device involved in the incident; location of incident; description of incident Type and brand of device involved in the incident; location of incident; description of incident. Any cuts, lacerations, punctures, and scratches will only need to be documented if they are work-related and involve contamination with another person's blood or other potentially infectious material. If the cut, laceration, or scratch involves a clean object, or a contaminant other than blood or other potentially infectious material, you need to record the case only if it meets one or more of the recording criteria in § 1904.7. The minimum information required consists of: · The type and brand of device involved in the incident; · Location of incident; and · Description of incident.

Kim is a new coder at XYZ Family Practice and she asks the Compliance Officer what is the maximum federal penalty amounts per false claim violation. What is the Compliance Officers response? a. Up to $10,781, plus the assessment of not more than three times the amount claimed for damages b. Up to $20,000, plus the assessment of not more than three times the amount claimed for damages c. Up to $25,000, plus the assessment of not more than three times the amount claimed for damages d. Up to $ 21,563, plus the assessment of not more than three times the amount claimed for damages

d. Up to $ 21,563, plus the assessment of not more than three times the amount claimed for damages Congress has increased the strength of the civil monetary penalty law over the years. The penalties for false claims is up to $21,563 per claim, plus the assessment of not more than three times the amount claims for damages.

The OIG Work Plan considers a number of factors, EXCEPT: a. mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directives b. requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget c. top management and performance challenges facing HHS d. inconvenience to the healthcare industry

d. inconvenience to the healthcare industry The OIG Work Plan considers a number of factors including: Mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directives; requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget; top management and performance challenges facing HHS; work performed by partner organizations; management's actions to implement our recommendations from previous reviews; and timeliness.

Persons found guilty of violating the Anti-Kickback Statute may be subject to a fine of up to how much? a.$15,000, imprisonment of up to five years, and exclusion from participation in federal health care programs for up to one year b.$10,000, imprisonment of up to five years, and exclusion from participation in federal health care programs for up to one year c.$25,000, imprisonment of up to ten years, and exclusion from participation in federal health care programs for up to one year d.$50,000, imprisonment of up to five years, and exclusion from participation in federal health care programs for up to one year

d.$50,000, imprisonment of up to five years, and exclusion from participation in federal health care programs for up to one year Persons found guilty of violating the anti-kickback statute may be subject to a fine of up to $50,000, imprisonment of up to five years, and exclusion from participation in federal health care programs for up to one year

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: participate in a quality assurance program maintain adequate hours of operation for the underserved community enroll In the CLIA program have a certificate of compliance

enroll In the CLIA program The CLIA law requires any laboratory performing testing on specimens derived from a human being for purposes of providing diagnosis, treatment, etc., to enroll in the CLIA program.

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. hospitals from admitting patients unable to pay and then transferring them to "charity hospitals" or "county hospitals." a hospital from incurring a large debt when a patient cannot afford to pay. on-call physicians from not showing up when there is an emergency.

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. EMTALA requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color.

A physician who fails to respond to an emergency situation when she is assigned as the on-call physician: is in violation of EMTALA, and may subject herself and the hospital to a penalty. is in violation of EMTALA because she should be on the hospital campus at all times when she is on call. is not in violation of EMTALA because she is only on call. is not in violation of EMTALA because EMTALA only relates to hospitals.

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

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

serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part An emergency medical condition is defined as having symptoms (including severe pain and psychiatric disturbances) such that the absence of immediate medical attention could result in: (1) placing the health of the individual (or unborn child) in serious jeopardy; (2) serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part. With a pregnant woman having contractions, an emergency medical condition also means there is not enough time to safely transfer the woman prior to delivery, or the transfer would pose a threat to her or her unborn child.

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 expense costs are more than the national average. when the expenses are a result of the imposition of a penalty. for the annual maintenance of the program. except the salary of the Compliance Officer.

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