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True or False: The ACA requires that all providers adopt a compliance plan as a condition of enrollment withMedicare, Medicaid, and Children's Health Insurance Program (CHIP). ANSWER :->>True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation inCompliance? (hint: protections) ANSWER:->>1.Protect our programs
- Protect your patients
- Protect the Provider At which level of the Medicare Part A or Part B appeals process is the appeal decision by theOffice 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 ANSWER:->>c.. third level of appeal Frist level - redetermination by Medicare contractor Second level - reconsideration by Independent contractorThird appeal
- Administrative Law Judge (ALJ) hearing Fourth appeal - review by Medicare Appeals Council Fifth appeal - review in Federal District Court https://www.hhs.gov/about/agencies/omha/the-appeals-process/index.html 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. ANSWER:->>a. Leadership skills, c. Skills to design and implement a compliance program, and d. Be able to anticipate new risk areas. Which of the following is an absolute necessity in order to have a successful ComplianceProgram? a. continuous training and improvements b. effective reporting path c. non-retaliation for whistleblowers d. reliable and equal discipline ANSWER:->>c. non-retaliation for whistleblowers
d. Social Security Act section 1128 ANSWER:->>c. Balance Budget Act of 1997 Also known as a BBA "three strikes rule" 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. ANSWER:->>a. Compliance programs are considered more dangerous if they are developed but not implemented. Formal statement outlining a plan for a specified subject area. It usually cites state and/or federalrequired actions or standards. a. CAP b. Procedure document c. Policy document d. Legal standards ANSWER:->>c. Policy document CAP - outlines corrective action plan
Procedure - describes process/steps under a certain criteriaLegal standards - mandatory action or rule Life cycle of records management ANSWER:->>Creation Use Maintenance Retention Disposition Standards of Conduct (written P&Ps) ANSWER:->>Demonstrate the organization's ethical attitude and its"enterprise-wide" emphasis on compliance with all applicable laws and regulations Code of Conduct: Content Checklist ANSWER:->>• Demonstrate system wide emphasis on compliancewith all applicable laws and regulations
- Written plainly and concisely so all employees can understand the standards
- Includes internal and external regulations
- Mentions organizational policies without completely restating them
- Is consistent with company policies and procedures
- Includes management's responsibility to explain and enforce the code
- 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? ANSWER:->>Must be distributed within 90 days of hire 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 ANSWER:->>a. b. d. The software can be used by other entities other than hospitals, so option "c." is not precisely accurate, but it is free to use and can be downloaded here: https://oig.hhs.gov/compliance/rat-stats/index.asp What is the term called for an organization's commitment to compliance by management, employees, and contractors. Statement should summarize ethical behavior and legal principlesunder which the healthcare
organization operates? ANSWER:->>Code of Conduct 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 withcurrent 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. ANSWER:->>b. Get HR involvedand recommend the use of progressive discipline policies OIG recommends setting forth the degrees of disciplinary actions. Progressive discipline provides a structure and a set of discipline standards for managers/supervisors to follow to ensure discipline is fair, equitable and consistent. Documentation ANSWER:->>• A&M should be documented
- Findings should be shared with dept managers
- promise that discipline will be fair and consistent New Employee Policy - three checks OIG recommends to do/perform: ANSWER:->>OIG recommends:perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? ANSWER:->>Code of Conductand P&Ps 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 ANSWER:->>b. detecting and preventingmisconduct 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 likelywritten by experts. c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use ageneral 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. ANSWER:->>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 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 healthcareorganization operates. A) Code of Conduct B) Federal Sentencing Guidelines C) Internal Controls ANSWER:->>A) Code of Conduct
D. Meet with legal to discuss how to best self-disclose to the OCR that the hospital was inviolation of the NPP requirements and has since corrected the deficiency ANSWER:->>B. Make arrangements to have the new notice distributed to new patients that come to the hospital Remember: The NPP must describe the following individual rights: https://www.law.cornell.edu/cfr/text/45/164.
- The right to request restrictions on uses or disclosures of PHI for treatment, payment or healthcare operations; for use in a facility directory (if applicable); or to family members and others involved in the patient's care; however, the provider is not required to agree to the restriction except in the case of a disclosure to a health insurer if the individual has paid for thecare as required by §164.522(a)(1)(vi). This is a change necessitated by the Omnibus Rule.
- The right to receive confidential communications by alternative means or at alternativelocations per §164.522(b).
- The right to inspect and copy PHI per § 164.524. The provider may want to include a statementthat the provider may charge a reasonable cost-based fee for copies.
- The right to amend PHI per § 164.526.
- The right to receive an accounting of disclosures of PHI as provided by § 164.528.
- The right to receive a paper copy of the NPP upon request.
- A brief description of how the individual may exercise the foregoing rights, e.g., by submittinga written request to the provider's privacy officer. 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 ANSWER:->>d. All of the above Remember: Fraud is generally defined as knowingly and willfully executing, or attempting toexecute, a scheme. 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 tounnecessary expenses What is the best definition of Medicare/Medicaid abuse? a. Knowingly defrauding the Medicare/Medicaid program b. Intentionally violating Medicare/Medicaid guidelines
b. federally administered and state monitored c. audited by MACs d. created to combat Medicare provider FWA ANSWER:->>a. established by the DRA of 2005 (section6034) https://www.ssa.gov/OP_Home/comp2/F109-171.html Notes: b. federally administered and state monitored (the opposite) c. audited by MACs (MIPs are audited by MICs) d. created to combat Medicare provider FWA (Medicaid, not Medicare) Reporting systems should be: a. marketed to contractors b. outsourced to a vendor c. operated by management d. publicized to all employees ANSWER:->>d. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider'sknowledge?
Yes No ANSWER:->>Yes - they are financially liable for all claims submitted on their behalf that contain their identification number 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 ANSWER:->>a. investigate the issue The False Claims Act contains a whistleblower-protection provision for persons reporting fraudand 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. B and C ANSWER:->>d. B and C 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 departmentor agency would that be? a. Equality in Employment Agency b. Office for Civil Rights c. Department of Justice d. Office of Inspector General ANSWER:->>b. Office for Civil Rights (OCR) DOL oversees employment discrimination DOJ enforces federal criminal law and implements criminal law policiesOIG combats FWA in Medicare, Medicaid and HHS Programs Note: practice question from AAPC CPCO Ch Which government department is comprised of thousands of employees who enforce the nation'sfederal 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 ANSWER:->>d. Department of Justice OIG combats FWA in Medicare, Medicaid and HHS Programs CMS administers the nation's major healthcare programs including Medicare, Medicaid, andCHIP to eliminate FWA HLA is an edu org (not a gov department) Note: practice question from AAPC CPCO Ch 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 ANSWER:->>a. HHS Office of Inspector GeneralNote: practice question from AAPC CPCO Ch What term would be used for actions that, either directly or indirectly, results in unnecessary costs to the Medicare program? a. Fraud
