HCA Certification Training

Fill in the blank: The Health ____ _______ Administration (HCFA) encouraged the use of statistical sampling to promote consistency in interpretation and establish FCA liability for claims submitted under Medicare

"Care Financing"

Code of Conduct: Employee Application 1. All employees must ______________ , ______________ , and ______________ the standards. 2. A ______________ should explain the standards and answer any questions. 3. Employee should ______________ in ______________ that they have received, read, and understood the standards 4. Employee compliance with standards must be ______________ through appropriate ______________ when necessary 4. ______________ for non-compliance should be stated in the standards

1. All employees must receive, read, and understand the standards. 2. A supervisor should explain the standards and answer any questions. 3. Employee should attest in writing that they have received, read, and understood the standards 4. Employee compliance with standards must be enforced through appropriate discipline when necessary 4. Discipline for non-compliance should be stated in the standards

Name three functions of Compliance Committee

1. Analyzing legal requirement and specific risk areas 2.Regularly reviewing and assessing policies and procedures 3. Assisting with the development of standards of conduct and policies and procedures 4. Monitoring internal systems related to standards, policies, and procedures 5. Determining the appropriate strategy to promote compliance 6. Developing a system to solicit, evaluate, and respond to complaints and problems

Which two main documents become tools to build compliance program?

1. Code of Ethical Conduct 2. Policy & Procedures

The place to start with Enforcement is:

1. Code of Ethical Conduct and, 2. Policies & Procedures

Name five obstacles to Effective Compliance Implementation

1. Commitment and buy-in 2. Lack of funding 3. Too many roles for compliance professional 4. Interpreting laws and regulations 5. Lack of resources and staff 6. Lack of education and training 7. Resistance to change 8. Lack of or poor communication 9. Fear of retaliation/retribution 10. No internal enforcement

What are the benefits to a Compliance Program?

1. Commitment to Code of Conduct. 2. Prevent, detect, and correct unethical behaviors. 3. Minimizes financial losses 4. Encourages employees to report compliance problems/issues

Code of Conduct: Content Checklist 1. Demonstrate ___________ _______ emphasis on _____________________ with all applicable laws and regulations 2. _____________ plainly and concisely so all employees can understand the standards 3. Includes ______________ and ______________ regulations 4. Mentions organizational ______________ without completely restating them 5. Is ______________ with company policies and procedures 6. Includes management's ___________________ to explain and enforce the code

1. Demonstrate system wide emphasis on compliance with all applicable laws and regulations 2. Written plainly and concisely so all employees can understand the standards 3. Includes internal and external regulations 4. Mentions organizational policies without completely restating them 5. Is consistent with company policies and procedures 6. Includes management's responsibility to explain and enforce the code

What are the two primary objectives of a Board of Directors (BOD)?

1. Duty of Care decision making 2. Oversight function (BOD can delegate to CEO)

What are the three things an effective compliance program can bring to your organization?

1. Enhance your organization's operations, 2. improve quality of patient care and, 3. reduce overall costs

Give three examples of current Compliance activities in many organizations.

1. Equal Employment Opportunity Commission (EEOC) 2. Employee Retirement Income Security Act (ERISA) 3. Wage and Hour Rule 4. Occupational Safety and health Administration (OSHA) 5. Nuclear Regulatory Commission 6. Joint Commission on Accreditation of Healthcare Organization (JCAHO) 7. Research compliance

Name three possible sanctions outcomes.

1. Fines 2. Restitution (pay restitution to victims) 3. Probation 4. Forfeiture (loss of any property or giving up something for wrongdoing)

What are the 2 types of OIG exclusions?

1. Mandatory (ex. criminal offenses) and, 2. Permissive (ex. misdemeanor convictions)

Name three benefits of a compliance program.

1. Safeguards organization legal responsibility to abide by applicable laws and regulations 2. Demonstrate organization's commitment to good corporate conduct 3. Identify and prevent criminal and unethical conduct 4. Create a centrilized source of info on healthcare regulations 5. Develop a methodology to encourage employees to report potential problem 6. Develop procedures that allow the prompt and through investigation of alleged misconduct 7. Initiate immediate and appropriate corrective action 8. Reduce organization remedies, such as program exclusion

Seven basic elements for a fundamental compliance program as per HCCA CHC exam?

1. Standards and Written Policies & Procedures 2. Compliance Program Admin (CO and Board oversight) 3. Effective Education &Training 4. Screening and Evaluation (Employees, Physicians, Vendors) 5. Communication, Edu & Training 6. Auditing & Monitoring, Internal Reporting System 7. Discipline for Non-Compliance 8. Investigation and Remedial Measures

Name 5 OIG Top 10 Reasons to Implement a Compliance Program

1. To demonstrate to the community at large the organization's commitment to good corporate conduct 2. To reinforce employee's innate sense of right and wrong 3. To help organization fulfill its legal duty to government and private payers 4. Compliance programs are cost effective 5. To provide a more accurate view of employee and contractor behavior relating to fraud and abuse 6. To improve quality of care overall 7. To provide procedures to promptly correct misconduct 8. To help mitigate any sanction imposed by the government 9. Voluntarily implementation is preferable than waiting for OIG to impose a Corporate Integrity Agreement (CIA) 10. To protect corporate directors from personal liability

Code of Conduct: Purpose 1. To present ______________ ______________ for employees to follow 2. To confirm that all employees ______________ what is required of them 3. To provide a ______________ for proper decision making 4. To confirm that employees put standards into ______________ ______________ 5. To ______________ corporate performance in basic business relationship 6. To confirm that the ______________ upholds and supports proper compliance conduct

1. To present specific guidelines for employees to follow 2. To confirm that all employees comprehend what is required of them 3. To provide a process for proper decision making 4. To confirm that employees put standards into everyday practice 5. To elevate corporate performance in basic business relationship 6. To confirm that the organization upholds and supports proper compliance conduct

What does Duty of Care mean for BOD?

1. act in good faith 2. level of care a prudent person would (avoid negligence) 3. protect welfare of organization, act in a manner that's best for all

What is important to state in a compliance non-retaliation policy?

1. anonymous reporting and, 2. no retaliation or retribution for bringing forth problems/concerns

The OIG recommends these three checks are preformed on new employees:

1. background checks, 2. reference checks, 3. exclusion list checks

For Enforcement and Disciplinary Actions, Policies should include: 1. 2. 3. 4. 5.

1. consequences 2. an employee's duty to report 3. a list of parties responsible for appropriate action 4. an outline of disciplinary actions or procedures 5. the promise that discipline will be fair and consistent

Training requirements for Compliance include:

1. engaging 2. thought provoking 3. positive call for action

What are the two primary focus areas of a Board of Directors (BOD) in compliance?

1. structural (need to understand compliance program SOW) 2. operational (need to understand compliance program needs to operate)

What are the three roles of a board member?

1.Compliance oversight. 2.Structuring your compliance program 3.Evaluating effectiveness of the compliance standards and processes.

According to HHS-OIG - what are three important reasons for proper documentation in Compliance? 1.Protect our ___________________ 2.Protect your ___________________ 3.Protect the ___________________

1.Protect our programs 2.Protect your patients 3.Protect the Provider

OIG can impose mandatory exclusion for a minimum of..?

5 years

A compliance program at its most basic level would be:

A set of internal policies and procedures that you put into place to help your organization comply with the law

What is the term called for an organization's commitment to compliance by the board, management, and employees? (It summarizes ethical behavior and legal principles the healthcare organization operates.) A) Code of Conduct B) Federal Sentencing Guidelines C) Internal Controls

A) Code of Conduct

Define compliance

Adherence to laws and regulations, as well as principles of ethical conduct

Fill in the blank: The ___________ ____ Act further required that the HHS Secretary, in consultation with HHS-OIG, establish "core elements" for provider and supplier compliance programs within a particular industry or sector.

Affordable Care

The board should review reports on the status of the compliance program, how often?

At least annually

The privacy officer for a hospital has updated the Notice of Privacy Practices to reflect a material change because the previous notice did not have a description that individuals have the right to amend their Protected Health Information. The third party review team identified that the notice did not have the required information to let individuals know of their right to amend PHI. What's the BEST course of action to correct deficiency? A. Make arrangements to have copies of the new NPP mailed to all patients seen within the last year at the hospital B. Make arrangements to have the new notice distributed to new patients that come to the hospital C. Post a copy of the new notice on the hospital's internal intranet so that all employees can see the updated version of the notice D. Meet with legal to discuss how to best self-disclose to the OCR that the hospital was in violation of the NPP requirements and has since corrected the deficiency

B. Make arrangements to have the new notice distributed to new patients that come to the hospital

The Hospital is attempting to open its files to a new Compliance Officer for review. What documentation is not critical for his review? A. The patient charts for the OB floor. B. The record of PHI breaches. C. The labs billing records. D. Contracts with Acme DME suppliers.

B. Records of PHI breaches Explanation: PHI breaches fall under Information security not Compliance activities. Records under Compliance activities include billing records, patient records, vendor contracts.

When creating and implementing a compliance plan, the compliance officer should have: A. no approval B. board approval and resolution C. patient approval D. legal approval

B. board approval and resolution

OIG urges the ____________ to assist in the implementation of the compliance program and serves as advisors. A. Board B. CEO C. Compliance Committee D. Quality Committee

C. Compliance Committee

What is the term called for an organization's commitment to compliance by management, employees, and contractors. Statement should summarize ethical behavior and legal principles under which the healthcare organization operates?

Code of Ethical Conduct

Health care Fraud is key priority in the Justice Department, and an effective _________ program safeguards the organization's legal responsibility to abide by applicable laws and regulations

Compliance

If there is a detection of serious wrongdoing, what is the first step for the compliance professional?

Contact Legal Counsel who can make the initial assessment of risks involved.

Life cycle of records management C U M R D

Creation Use Maintenance Retention Disposition

February 27, 1997, what does this date represent?

Date of OIG open letter to all providers - encourages health care organization to implement compliance programs in order to protect themselves from fraud and abuse. With that letter, Model compliance plan for Clinical Laboratory was offered as guidance. Since that time, a Model compliance plan has been implemented in many areas.

In all OIG program guidance, what's the first element they call for?

Development and distribution of written standards of conduct, as well as written policies and procedures that promote a commitment to compliance.

You have done a compliance plan. What comprises a compliance program? A. Budget B. Resources C. Compliance Board D. CO E. All of the above

E. All of the above

True or False: The entity's level of commitment to compliance is directly related to the resources (human and financial).

False

True or False An excluded individual is automatically reinstated at the end of an exclusion term

False An excluded individual must apply for reinstatement at the end of their exclusion term

True or False: The Compliance Officer imposes disciplinary actions?

False Compliance only recommends actions

True or False: Billing errors always show a health care provider's or supplier's intent to commit fraud.

False Not all improper payments are fraud, but all payments made due to fraud schemes are improper (that is, an intentional misuse of funds). In fact, most improper payments are due to unintentional errors. Most common error is insufficient documentation.

What provided the groundwork for compliance program development?

Federal Sentencing Guidelines (FSG)

What is the appeals process is the appeal decision by the Office of Medicare Hearings and Appeals (OMHA)? Frist level - _________________________ Second level - _________________________ Third appeal - _________________________ Fourth appeal - _________________________ Fifth appeal - _________________________

Frist level - redetermination by Medicare contractor Second level - reconsideration by Independent contractor Third appeal - Administrative Law Judge (ALJ) hearing Fourth appeal - review by Medicare Appeals Council Fifth appeal - review in Federal District Court

If you find you actually are doing something wrong, corrective actions should be put in place. For instance, if you identified an overpayment, your FIRST action is to refund to the Fiscal Intermediary. If you suspect the possibility of serious wrongdoing that may affect your organization's reputation, your FIRST action is to contact legal/attorney to assess if attorney-client privilege needs to be attached. If you identified that certain employees are not properly being disciplined for misconduct, your FIRST action is to work with _________ and recommend that discipline should be fair, equitable and consistent.

Human Resources

OIG Work Plan, what's its main purpose?

Identifies high risk & key areas of focus for auditing.

Every organization needs policies and procedures for: (Name Three)

Internal assessments Record retention (where, how long) Self-disclosure Medicare sanction checks (LEIE) Billing policies Credit balance No charge visits Incomplete/unsuccessful procedure Documentation requirements

When should Code of Conduct be distributed to new employees?

Must be distributed within 90 days of hire

Fill in the blank: The Healthcare Fraud and Abuse Control (HFCA) program requires the ___ and ___ to coordinate federal, state, and local health care law enforcement activities, provide guidance to providers on fraudulent practices, and establish a national data bank to receive and report final adverse actions against providers.

OIG and DOJ

One of the processes for risk identification is document review, including OIG key compliance documents. Name two of the documents that should be considered for review

OIG workplan and bulletins, Advisory Opinions, Special Fraud Alerts, and other guidance

This demonstrates the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations

Policies and Procedures

What are the three principles HCCA prepared and published Code of Ethics for Health Care Compliance Professional?

Principle 1 - Obligation to public Principle 2 - Obligation to employing organization - should serve organization with highest sense of integrity, unprejudiced, and unbiased judgment Principle 3 - Obligation to the profession - uphold integrity and dignity of profession, to advance effectiveness of compliance program and to promote professionalism in health care compliance

When there is poor distribution beyond the compliance officer, what happens to the organization?

Program Implementation lags which means you do not have an effective compliance program

If a provider is on the OIG sanctions list, what do you do first?

Put provider on Administrative Leave

This Act mandates compliance programs for Medicare, Medicaid and Children's Health Insurance Program (CHIP) providers

The Affordable Care Act (ACA)

Which Act created the Medicaid Integrity Program to ensure that Medicaid payments are for covered services that were actually provided, properly billed and documented; and requires that entities receiving more than $5 MIL in annual Medicaid payments establish written policies and educate employees on the FCA and whistleblower protections to prevent and detect Fraud, Waste and Abuse?

The Deficit Reduction Act (DRA) of 2005 created the Medicaid Integrity Program (MIP) under Section 1936 of the Social Security Act.

Education (effective training) is. . .

The most important lines of defense for a compliance program. The education (& training) is the best strategy for prevention.

True or False: A good compliance program will identify problems from time to time, if it doesn't, that's a sign that what you're doing is NOT effective

True

True or False: The OIG requests that you post on your website whether or not the PHRMA CODE is followed.

True

True or False: Regarding Attorney-Client Privilege, the procedure called "Upjohn warning," in which a company's lawyer explains that the lawyer represents the company and not the individual employee with whom the lawyer is dealing.

True

True or False: The ACA requires that all providers adopt a compliance plan as a condition of enrollment with Medicare, Medicaid, and Children's Health Insurance Program (CHIP).

True

True or False: If an IRO identifies any underpayments during a CIA-Claim Review for a hospital, these may be netted (or offset) from overpayments. The hospital may also consult with the appropriate payor to ensure if the underpayment amounts can be used against outstanding overpayments.

True For purposes of reporting the overpayment to the OIG, underpayments may be netted (or offset) from overpayments. However, in terms of repaying the overpayment to the appropriate payor, the provider should consult with that payor as to whether it will allow underpayments to be netted from overpayments for collection purposes.

True or False: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is a joint anti-fraud initiative between the HHS and DOJ.

True HEAT task forces are interagency teams comprised of top-level law enforcement and professional staff members to prevent fraud and enforce anti-fraud laws. HHS and DOJ increase coordination, data sharing, and training among investigators, agents, prosecutors, analysts, and policymakers.

True or False: A hospital with an imposed-CIA performs a discovery sample as part of the Claim Review and finds it has a financial error rate above 5%. OIG requires that the hospital then conducts a full sample.

True Probe and Discovery Samples are used to get an initial glimpse and seriousness of a problem to determine if the size of a Full Sample is needed. For example, in Corporate Integrity Agreements (CIA) the OIG requires a Full Sample to be used, if the overpayment error rate, or financial error rate, in a Discovery Sample is at or above 5%.

True or False: Providers are financially liable if their billing services commit fraud without the provider's knowledge?

True They are financially liable for all claims submitted on their behalf that contain their identification number

Which of the following statements is false regarding Statistically Valid Sampling? a. ACA encouraged the use statistical sampling and extrapolation to promote consistency for claims submitted under Medicare. b. develop policies & procedures to address statistical sampling and financial error rate considerations for refunds/overpayments identified c. for CIA claim reviews, if the net financial error rate equals or exceeds 5%, the results of the Discovery Sample are used to determine the Full Sample size d. Audit sampling can be applied using either statistical or non-statistical sampling approaches

a. ACA encouraged the use statistical sampling and extrapolation to promote consistency for claims submitted under Medicare.

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

a. Adopt only those components which, based on the practice's specific history with billing problems and other compliance issues, are most likely to provide an identifiable benefit.

Which statement is TRUE regarding compliance programs? a. Compliance programs are considered more dangerous if they are developed but not implemented. b. Compliance programs can detect but not prevent criminal conduct c. Compliance programs are only required by law for healthcare entities that have more than $500,000 in annual revenue. d. Compliance programs are not mandated by law.

a. Compliance programs are considered more dangerous if they are developed but not implemented.

A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from Medicare/Medicaid. Is this violation fraud, abuse, or neither? a. Fraud b. Abuse c. Neither

a. Fraud

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

a. HHS Office of Inspector General

When should counsel be involved during an internal investigation? a. If corporation may have to disclose inappropriate conduct and take remedial action. b. If there is an inadvertent billing error. c. If there is a question about the training program. d. If there is fraudulent behavior that the CCO wants to cover up.

a. If corporation may have to disclose inappropriate conduct and take remedial action.

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

a. It shows that the practice is making a good faith effort to be compliant

What should CCO be able to do? (What skills should this person have?) Choose all that apply: a. Leadership skills. b. Oversee the coding department. c. Skills to design and implement a compliance program. d. Be able to anticipate new risk areas. e. Practical experience with documenting medical necessity.

a. Leadership skills, c. Skills to design and implement a compliance program, and d. Be able to anticipate new risk areas.

If I'm only doing blood draws, do I need a CLIA number? a. No, a CLIA number is not required if the facility only collects specimens and performs no testing. b. No, a CLIA number is not required if the facility only collects specimens and performs minor testing. c. Yes, a CLIA number is required if the facility only collects specimens, even if they perform no testing. d. Yes, a Medicare-participating provider that only collects specimens requires a CLIA number.

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

How does Medicaid work? Select 2 a. State administered b. Federally administered c. State monitored d. Federally monitored

a. State administered (via SURS and MFCUs); d. Federally monitored (OIG oversights each state MFCU's operational costs)

Regarding statistical sampling, what is an example of failed efforts to use statistical analysis? a. Users who did not understand subject matter or application of sampling. b. A well-rounded data sample c. Knowledgeable staff who are involved in the process d. Investigations done of improper billing practices

a. Users who did not understand subject matter or application of sampling.

RAT-STATS is: (select all that apply) a. statistical software to select randomized samples b. government statistical rule software developed in the 1970s c. free hospital statistical software d. recommended by OIG, CMS and other agencies to select random samples

a. b. d.

What is true about Medicaid Integrity Programs: a. established by the DRA of 2005 b. federally administered and state monitored c. audited by MACs d. created to combat Medicare provider FWA

a. established by the DRA of 2005

A compliance professional is conducting a policy review. Which of the following procedures MUST be included in the policy for statistically valid sampling and extrapolation? a. financial error rate exceeds 5% with a refund to occur within 60 days b. financial error rate exceeds 5% with a refund to occur within 90 days c. coding error rate exceeds 5% with a refund to occur within 60 days d. coding error rate exceeds 5% with a refund to occur within 90 days

a. financial error rate exceeds 5% with a refund to occur within 60 days

An employee reports a potential problem with the attending physician's presence for surgery. Which of the following is the compliance professional's BEST action? a. investigate the issue b. approach the surgeon c. notify the OIG d. request copies of the records

a. investigate the issue

The U.S. Federal Sentencing Commission was organized in _____, published its initial set of guidelines in _____, and included chapter eight of the Federal Sentencing Guidelines for Organizations (FSGO) in _____. a. 1980, 1987, 1999 b. 1985, 1987, 1991 c. 1980, 1985, 1987 d. 1985, 1990, 2001

b. 1985, 1987, 1991

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

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

In the course of an audit, you find that disciplinary actions against certain physicians and high level executives for non-compliance in the organization have been unfair and inconsistent with current policies & procedures. What is your first course of action . a. Work with legal counsel to enforce proper disciplinary actions b. Get HR involved and recommend the use of progressive discipline policies c. Immediately terminate these individuals d. Get local and federal labor department involved for unfair discipline.

b. Get HR involved and recommend the use of progressive discipline policies

What is RAT STATS? a. Government hotline for fraud and abuse b. Government statistical rules (for example sample size) c. Hospital technology for tracking sampling d. Statistical software for hospitals to use

b. Government statistical rules (for example sample size)

A hospital medical staff office is conducting its monthly review of the Excluded Parties List System (EPLS). The compliance officer is called by the manager of the medical staff office and informed that Dr. Smith, a surgeon who took call 5 times last month for the Emergency Department, was excluded on a date prior to those dates when the surgeon took call. In other words, the effective date of the exclusion involving the surgeon was 4/1/2019 and the surgeon took call and provided surgical services to patients in the ED on 4/13/19, 4/20/19, and 4/27/2019. What is the NEXT action the compliance officer should do? a. Contact the ED and make sure that the involved surgeon is removed from taking any more on call shifts. b. Have the medical office check if the surgeon is listed on other exclusion lists. c. Contact legal counsel to alert of the need to pay back reimbursement received for services provided by an excluded individual. d. Hold all surgical service related bills associated with the ED so that none are released to any payers which may involve this surgeon

b. Have the medical office check if the surgeon is listed on other exclusion lists.

Which of the following agencies indicate a self-evaluation after discovery of potentially fraudulent acts? a. CMS b. OIG c. OCR d. OSHA

b. OIG

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

b. OIG's Clinical Lab Guidance

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

b. Office for Civil Rights (OCR)

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

b. Regularly review and update the compliance program.

What can a provider do if they are unhappy with an informal review by the state Medicaid Program/SUR unit? a. Dispute the informal review with the SUR. b. Request an administrative hearing. c. Request that the informal review be made into more understandable education. d. Request that the Fiscal Intermediary take back the repayment.

b. Request an administrative hearing

You are the new compliance officer for a hospital and see that it is currently under an OIG CIA. What would be the first course of action in your new position? a. Review the current OIG Work Plan and update the audit schedule for the hospital. b. Review the Code of Conduct and Policies and Procedures and update them as appropriate. c. Meet with the Compliance Board and discuss your vision of how compliance will be run in the future. d. Review the audit schedule and pick up where the previous compliance officer left off.

b. Review the Code of Conduct and Policies and Procedures and update them as appropriate.

One of the most important foundations of your compliance program is: a. The Compliance Policy Manual b. The Organization Code of Conduct c. The non-retaliation policy d. Adequate staffing and information systems

b. The Organizational Code of Conduct

The IRO is conducting a Claim Review for a hospital under a CIA and discovers that there is a discrepancy between the dollar difference between the amount that was reimbursed and the amount that should have been reimbursed when conducting a Discovery Sample. Which of the following is false: a. The dollar difference resulted in an overpayment. And when converted to percentage, the resulting calculation is the error rate b. The net financial error rate calculated was under 10%, no need to conduct a Full Sample c. If the net financial error rate of the Discovery Sample is below 5%, the review is complete d. A and C

b. The net financial error rate calculated was under 10%, no need to conduct a Full Sample According to the OIG, a Full Sample size is only required if the net financial error rate of the Discovery Sample equals or exceeds 5%.

Related to Corporate Integrity Agreements with the government, what is an IRO and what are the details of how it works? Choose 2 answers. a. Independent Reorganization Operation. b. They do the auditing required by a CIA. c. The OIG hires them. d. They need to be fair and unbiased and can't have a financial relationship with the hospital.

b. They do the auditing required by a CIA. d. They need to be fair and unbiased and can't have a financial relationship with the hospital. Explanation: IROs need to meet criteria and follow the AICPA and SEC guidance (unbiased judgement, honest neutrality, and demonstrate independence among other requirements)

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

b. When the expenses are a result of the imposition of a penalty. 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

What is the ultimate goal of having a Compliance Program in place? a. ensuring coders and billers are properly trained to ensure compliance with the FCA b. detecting and preventing misconduct c. auditing and monitoring key hospital department areas to mitigate risks identified d. aligning organizational compliance efforts with legal and HR

b. detecting and preventing misconduct

A Compliance Officer can achieve a higher level of compliance and ethics engagement by: a. ensuring leadership reads the policies b. increasing management involvement c. responding to compliance hotline calls d. monitoring the code of conduct

b. increasing management involvement

Leaf Hospital is trying to determine what the goal and focus of their compliance program should be. What would you say, as a compliance officer at your own hospital, to help them with what the compliance department goal should be from a monitoring and auditing perspective? a) Train coders in how to properly code claims. b) Keep track of the CEO's involvement with public affairs. c) Detect and prevent criminal conduct. d) Hire revenue management staff.

c) Detect and prevent criminal conduct Explanation: The Federal Sentencing Guidelines says M&A done by compliance program should be designed to detect and prevent criminal conduct. From Chapter 4 of the Auditing and Monitoring book 2nd ed

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

c. 10 State rules differ regarding background checks: 43 states require nursing homes to perform background checks against state records, 10 of those require an additional FBI background check, and eight states don't require background checks at all.

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

c. 43

The Board of Directors involvement with compliance includes all except: a. Written endorsement b. Allocating sufficient budgetary resources c. Active role in the daily compliance operations d. Establishing compensation structures that reward compliance

c. Active role in the daily compliance operations

Which of the following requires providers to be permanently excluded from all federal health care programs if found guilty of a healthcare related fraud a third time: a. Deficit Reduction Act of 2005 b. False Claims Act c. Balance Budget Act of 1997 d. Social Security Act section 1128

c. Balance Budget Act of 1997 Also known as a BBA "three strikes rule"

What is a benefit of a contemporaneous review? a. Can provide a chance to do a self-disclosure of prior billing errors b. Helps with creating a code of ethics c. Can correct a problem before it grows to become a serious issue d. Allows employees to submit anonymous reports of fraud

c. Can correct a problem before it grows to become a serious issue.

Which certificate is issued to a laboratory that enables the entity to conduct moderate- to high-complexity laboratory testing until the entity is determined by survey to comply with the CLIA regulations a. Certificate of Compliance b. Certificate for Provider-performed Microscopy procedures c. Certificate of Registration d. Certificate of Waiver

c. Certificate of Registration.

The following questions would be pertinent to every organization to help the __________________ professional in reviewing policies and procedures that need to be addressed: Does the organization employ non-physician practitioners? Does the organization perform services in a rural clinic settings? Does the organization provide medical services that fall under the Physicians at Teaching Hospital (PATH) rules? Does the organization participate in clinical trials (research)? a. Human Resources Director b. Chief of Hospital Operations c. Chief of Compliance d. Medical Staff Services

c. Chief of Compliance

Which is not one of the seven fundamental elements of an effective compliance program? a. Implementing written policies, procedures, and standards of conduct. b. Conducting effective training and education. c. Developing policy guidance summaries. d. Responding promptly to detected offenses and undertaking corrective action.

c. Developing policy guidance summaries.

he Federal Sentencing Guidelines uses 2 mitigating factors (but in reality are 4 factors), which are: a. Effective compliance program, reporting the violation promptly, awareness of the violation, and accepts responsibility for the violation. b. Willfully ignorant of the offense, repeat violation, government investigation was hindered and tolerance of the violation was pervasive. c. Effective compliance program, reporting the violation promptly, cooperate with government investigation and accepts responsibility for the violation. d. Effective compliance program, first offense, cooperate with government investigation and accepts responsibility for the violation.

c. Effective compliance program, reporting the violation, cooperate with government investigation, and accepts responsibility for violation (effective prog, and report - cooperate - accept)

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: a. Participate in a quality assurance program b. Maintain adequate hours of operation for the underserved community c. Enroll in the CLIA program d. Have a certificate of compliance

c. Enroll in the CLIA program

Fill in the blank: _______ occurs when someone intentionally deceives or makes misrepresentations to get money or property from any health care benefit program. a. Abuse b. Improper payment c. Fraud d. None of the above

c. Fraud Fraud occurs when someone intentionally (knowingly/willfully) deceives or makes misrepresentations to get money or property of any health care benefit progra

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

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

How often does The U.S. Department of Health & Human Services (HHS) OIG publish the OIG Work Plan? a. Annually b. Bi-annually c. Monthly d. Weekly

c. Monthly

The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? a. Persons reporting fraud or abuse may be subject to the same penalties as the persons committing the fraud or abuse. b. Persons reporting fraud or abuse can be discharged or demoted. c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. d. Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position.

c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.

Formal statement outlining a plan for a specified subject area. It usually cites state and/or federal required actions or standards. a. CAP b. Procedure document c. Policy document d. Legal standards

c. Policy document

Related to Legal Doctrines for Protection from Disclosure to protect certain documents during the course of discovery. What is the work product doctrine? a. Ensures that attorney documentation is accessible to the hospital. b. Ensures that attorney documentation is accessible to the OIG. c. Protects attorney documents that were prepared for litigation purposes. d. Allows the hospital to protect documents sent to the attorney.

c. Protects attorney documents that were prepared for litigation purposes

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

c. Providers should put patients first in a compliance program.

You are the new Compliance Officer, hired after ABC Hospital reorganized and decided that the General Counsel should no longer also serve in that role. Upon review of the Code of Conduct (CoC), you find that it is written using lots of legal jargon. What action do you take: a. Keep CoC as it is. b. Pull a sample off the internet and insert hospital name to save time as it was most likely written by experts. c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance. d. Rewrite the CoC with detailed restating hospital's P&Ps, and all laws and regulations possible so that employees can't say they were not aware of requirements.

c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance. Explanation: CoC should be clear and concise language easy to understand, and should be tailored to specific issues of the organization

The largest and oldest accrediting body for healthcare organizations in the United States, which has accredited more than 22,000 organizations is: a. World Health Organization b. American Medical Association c. The Joint Commission d. National Committee for Quality Assurance

c. The Joint Commission

What is the best definition of Medicare/Medicaid abuse? a. Knowingly defrauding the Medicare/Medicaid program b. Intentionally violating Medicare/Medicaid guidelines c. Unknowingly violating Medicare/Medicaid guidelines d. None of the above

c. Unknowingly violating Medicare/Medicaid guidelines FRAUD is intentional; WASTE is overuse/misuse of resources carelessly; ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses

Which of the following is an absolute necessity in order to have a successful Compliance Program? a. continuous training and improvements b. effective reporting path c. non-retaliation for whistleblowers d. reliable and equal discipline

c. non-retaliation for whistleblowers

At which level of the Medicare Part A or Part B appeals process is the appeal decision by the Office of Medicare Hearings and Appeals (OMHA)? a. first level of appeal b. second level of appeal c. third level of appeal d. fourth level of appeal

c. third level of appeal

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

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

d. Abuse

The code of conduct should address the organization's: a. Culture b. Beliefs c. Ethical position d. All of the above

d. All of the above

The compliance plan should be reviewed: a. When the OIG issues new guidelines b. When a new regulation is passed c. At least annually d. All of the above

d. All of the above

What is the best definition of Medicare/Medicaid fraud? a. Attempting a scheme against the Medicare/Medicaid program b. Knowingly executing a scheme against the Medicare/Medicaid program c. Willfully executing a scheme against the Medicare/Medicaid program d. All of the above

d. All of the above FRAUD is intentional; WASTE is overuse/misuse of resources carelessly; ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses

When developing an effective code of conduct, an organization should consider: a. Soliciting another organization's code and tweaking it to fit b. Methods for reporting issues c. Zero tolerance for fraud and abuse d. B and C

d. B and C

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

d. Department of Justice

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

d. Drug Enforcement Agency

ABC Hospital is under a 5-year CIA with government-imposed requirements for development of a Compliance Program and use of external auditor for periodic claim reviews. Which of the following is TRUE: a. Costs to meeting terms of the CIA are permitted to be included in the cost report like any other operational cost. b. Because the hospital agreed to a settlement and was not convicted for alleged violations, the Compliance Program is considered a voluntary program. c. The government chooses and pays for the external auditors. d. None of the above

d. None of the above. Explanation: 1. CIA-related costs CANNOT be included in the cost report. 2. Government-imposed Compliance Program ARE NOT considered a voluntary program. 3. Hospital is required to choose and pay for any auditors (with government review and right to object)

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

d. Patients

Health Care Financing Administration (HCFA) encouraged one of the following to promote consistency in interpretation of claims? a. Education b. Reporting c. Discipline d. Statistical sampling

d. Statistical sampling

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

d. The compliance program should be continually a work in progress.

Reporting systems should be: a. marketed to contractors b. outsourced to a vendor c. operated by management d. publicized to all employees

d. publicized to all employees

A Compliance Program with well written policies and procedures: a. can be successful if consistently reviewed and maintained b. cannot be effective due to the sheer volume presented c. will be effective if read by management d. will not be successful without the proper oversight

d. will not be successful without the proper oversight

What are some obstacles to an effective compliance program? a. Lack of funding b. Resistance to change c. Fear of retaliation d. Lack of education and training e. All of the above

e. All of the above

What is the purpose of a Compliance Committee?

to advise the compliance officer and assist in the implementation of the compliance program