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TESTBANK FOR HCCA-CHC EXAM STUDY PACK| Latest Questions With Verified Answers | 2025-2026 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). Vv True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) VV Protect our programs https://oig.hhs.gov/newsroom/podcasts/201 I/heat/heat09- trans.asp#:~:text—Proper%20documentation%2C%20both%20in%20patients,to%20protect%20y ou%20the%20provider. 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 4. fourth level of appeal Ve. 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. 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. VVa. Leadership skills, b. increasing management involvement ¢. responding to compliance hotline calls 4. monitoring the code of conduct VW, inéreasing 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 VV. 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. ¥Va. Compliance programs are considered 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 4. Legal standards We, Policy document CAP - outlines corrective action plan Procedure - describes process/steps under a certain criteria Legal standards - mandatory action or rule Life cycle of records management VV Creation 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 ¥V¥* 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: ¥V* 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 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 ¥ Va. 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 + 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: / VFor 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. * anonymous reporting and, * no retaliation or retribution for bringing forth problems/concerns Place to start with Enforcement is: VV Standards of conduct and P&Ps For Enforcement and Disciplinary Actions, Policies should include: ¥ V1. non-compliant consequences 2. employees duty to report non-compliance 3. list parties responsible for appropriate action 4. outline of disciplinary actions or procedures 5. promise that discipline will be fair and consistent New Employee Policy - three checks OIG recommends to do/perform: ¥ ¥OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? ¥ ¥ Code of Conduct and 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 V Vb. 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. 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 / vb. 1985, 1987, 1991 "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 VV 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/45/164.520 + 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. c. Unknowingly violating Medicare/Medicaid guidelines d. None of the above V Vc. Unknowingly violating Medicare/Medicaid guidelines FRAUD is intentional (knowingly/willfully); 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 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 Va. Fraud Upcoding - is a type of fraud (knowing/intentionally) coding more expensive codes for higher reimbursement 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 JV Va. 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 / Vd. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider's knowledge? d. Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. / Vc. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. The entity's level of commitment to compliance is directly related to the resources (human and financial) a. True b. False VV b. False The code of conduct should address the organization's: a. Culture b. Beliefs c. Ethical position d. All of the above VV d. All of the above 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. Band C VVd. Band 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 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 V Vb. Office for Civil Rights (OCR) DOL oversees employment discrimination DOJ enforces federal criminal law and implements criminal law policies OIG combats FWA in Medicare, Medicaid and HHS Programs Note: practice question from AAPC CPCO Chl 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 
