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HCCA- CHC FINAL EXAM, PRACTICE EXAM AND
STUDY GUIDE /ACTUAL EXAM WITH 600+
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH EXPLANATIONS (VERIFIED ANSWERS)
|ALREADY GRADED A+/ NEWEST 202 5
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 ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) ✔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 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 e. ✔c.. third level of 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 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.
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 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 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" 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.
Retention Disposition Standards of Conduct (written P&Ps) ✔Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations Code of Conduct: Content Checklist ✔• Demonstrate system wide emphasis on compliance with 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 Ref: SCCE Compliance & Ethics Manual, Chapter 2 https://compliancecosmos.org/essential- elements-effective-ethics-and- compliance-program
Code of Conduct and Employees ✔All employees must receive, read, and understand the standards. A supervisor should explain the standards and answer any questions. Employee should attest in writing that they have received, read, and understood the standards Employee compliance with standards must be enforced through appropriate discipline when necessary Discipline for non-compliance should be stated in the standards Code of Conduct Purpose ✔• To present specific guidelines for employees to follow
- To confirm that all employees comprehend what is required of them
- To provide a process for proper decision making
- To confirm that employees put standards into everyday practice
- To elevate corporate performance in basic business relationship
- To confirm that the organization upholds and supports proper compliance conduct Every organization needs policies and procedures for: ✔• Internal assessments
- Record retention (where, how long)
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 principles under which the healthcare organization operates? ✔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 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 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 ✔• A&M should be documented
- Findings should be shared with dept managers
- If activity is part of risk priority then compliance committee, senior leadership and board when necessary
- OIG calls for written evaluation to be presented to CEO, governing body, committee annually Non-retaliation in compliance - what is important to state in this policy: ✔For any reporting method to be effective, employees must accept that there will be no retaliation or retribution for coming forward. The concept of non-retaliation is fundamental to the compliance program, and a clearly stated policy regarding non-retribution is the first step.
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 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 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 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
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 the care 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 alternative locations per §164.522(b).
- The right to inspect and copy PHI per § 164.524. The provider may want to include a statement that 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 submitting a 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 ✔d. All of the above Remember: Fraud is generally defined as knowingly and willfully executing, or attempting to execute, 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 to unnecessary expenses 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
c. audited by MACs d. created to combat Medicare provider FWA ✔a. established by the DRA of 2005 (section 6034) 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 ✔d. publicized to all employees Are providers financially liable if their billing services commit fraud without the
provider's knowledge? Yes No ✔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 ✔a. investigate the issue 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,
