CHAA Exam Review Questions with Verified
Correct Answers
TRICARE
A healthcare program for military active, reservists, and retirees and families. Active-duty
service members are automatically enrolled in TRICARE. Retirees and their dependents can
enroll in TRICARE but may have to pay for the cost of coverage.
-Tricare is secondary to all other insurance plans, except Medicaid
-Tricare is not considered a group health plan
Unbundling
Fraudulent practice of breaking down services currently bundled together in one CPT code
into individual codes for the purpose of higher reimbursement.
Upcoding
Process of assigning an inaccurate billing code for a medical procedure or treatment to
increase reimbursement, considered to be a fraudulent billing practice.
Verification of Physician
Be sure to verify that the physician who will be treating the patient is on the panel of
providers for the patient's insurance. This is especially important when a patient comes in
who is unassigned (does not have a primary care physician) and will be accepted by the
physician on call.
Veterans Administration (VA)
,Largest integrated healthcare system in America serving veterans who served in the active
military for at least 24 continuous months and were discharged or released under any
condition other than dishonorable (some exceptions exist).
Veterans Choice Program
Program where the VA enrolled member is authorized to receive care from community-based
providers.
Care is authorized when their local VA health care facility is unable to provide services due
to:
-Medical care at the VA is not available for at least 30 days or extended wait times for
appointments
-Lack of available specialists in the area
-Patient lives more than 40 miles from a VA medical care facility
-When traveling creates excessive travel burdens
Office of the Inspector General (OIG)
Is a division of the US Department of Health and Human Services (HHS). It is the OIG's
responsibility to protect the integrity of HHS programs and the well-being of beneficiaries by
detecting and preventing fraud, waste and abuse; improve program efficiency and
effectiveness; and holding accountable those who do not meet program requirements or
violate the federal healthcare law. The two major programs under HHS are Medicare and
Medicaid.
The OIG is also responsible for educating the public about fraudulent schemes so they can
protect themselves and know how to report suspicious activities. Some of the more common
fraud laws include: The Stark Law, the Anti-Kickback Statute and the False Claims Act.
,Purpose of a Compliance Program
The OIG states that "compliance is a dynamic process that helps to ensure that hospitals and
other healthcare providers are better able to fulfill their commitment to ethical behavior, as
well as meet the changes and challenges being imposed upon them by Congress and private
insurers." With the establishment of a voluntary compliance program and a designated
hospital compliance officer, hospitals will be able improve the quality of patient care,
substantially reduce fraud, waste and abuse, and reduce the cost of healthcare to federal, state
and private health insurers.
Elements of a Compliance Program include:
I. Establish compliance standards, procedures and policies
II. Assign oversight responsibility for compliance to an individual high in the organization's
structure (i.e., dedicated compliance officer and a compliance committee)
III. Screening and evaluation of employees, physicians, vendors
IV. Communication, education and training on compliance issues
V. Monitoring, auditing and the establishment of internal reporting systems (e.g., anonymous
hotlines, email, etc.)
VI. Discipline for non-compliance
VII. Respond appropriately and immediately to detected offenses
What components of the establishment of compliance standards, procedures and
policies have an impact on Patient Access?
-Code of conduct
-Admission policy
-Discharge policy
-Patient referrals
, -Physician agreements
-Claim development
Name some special areas at high risk for non-compliance:
-Billing for items or services not rendered
-Providing medically unnecessary services
-Upcoding
-Outpatient services rendered in connection with inpatient stays
-Duplicate billing
-Unbundling
-Patients' freedom of choice
-Credit balances
Name some provisions of the The Patient Protection and Affordable Care Act
(PPACA):
-Ensure access to health insurance and protect against unaffordable out-of-pocket costs
-Tax credits established for low-income Americans
-Eliminating lifetime limits on benefits
-Provide assistance for those with pre-existing conditions
-Extend dependent coverage up to age 26
-Expand Medicaid coverage to more low-income Americans
-Reduce the prescription drug coverage gap ("donut hole") for those receiving the Medicare
Part D Prescription Drug Benefit. A whole title of the law focuses on Medicare reform.
-Require coverage of preventative services and immunizations
-Establish internet portals to assist with the identification of coverage options (e.g., The
Exchange)
Correct Answers
TRICARE
A healthcare program for military active, reservists, and retirees and families. Active-duty
service members are automatically enrolled in TRICARE. Retirees and their dependents can
enroll in TRICARE but may have to pay for the cost of coverage.
-Tricare is secondary to all other insurance plans, except Medicaid
-Tricare is not considered a group health plan
Unbundling
Fraudulent practice of breaking down services currently bundled together in one CPT code
into individual codes for the purpose of higher reimbursement.
Upcoding
Process of assigning an inaccurate billing code for a medical procedure or treatment to
increase reimbursement, considered to be a fraudulent billing practice.
Verification of Physician
Be sure to verify that the physician who will be treating the patient is on the panel of
providers for the patient's insurance. This is especially important when a patient comes in
who is unassigned (does not have a primary care physician) and will be accepted by the
physician on call.
Veterans Administration (VA)
,Largest integrated healthcare system in America serving veterans who served in the active
military for at least 24 continuous months and were discharged or released under any
condition other than dishonorable (some exceptions exist).
Veterans Choice Program
Program where the VA enrolled member is authorized to receive care from community-based
providers.
Care is authorized when their local VA health care facility is unable to provide services due
to:
-Medical care at the VA is not available for at least 30 days or extended wait times for
appointments
-Lack of available specialists in the area
-Patient lives more than 40 miles from a VA medical care facility
-When traveling creates excessive travel burdens
Office of the Inspector General (OIG)
Is a division of the US Department of Health and Human Services (HHS). It is the OIG's
responsibility to protect the integrity of HHS programs and the well-being of beneficiaries by
detecting and preventing fraud, waste and abuse; improve program efficiency and
effectiveness; and holding accountable those who do not meet program requirements or
violate the federal healthcare law. The two major programs under HHS are Medicare and
Medicaid.
The OIG is also responsible for educating the public about fraudulent schemes so they can
protect themselves and know how to report suspicious activities. Some of the more common
fraud laws include: The Stark Law, the Anti-Kickback Statute and the False Claims Act.
,Purpose of a Compliance Program
The OIG states that "compliance is a dynamic process that helps to ensure that hospitals and
other healthcare providers are better able to fulfill their commitment to ethical behavior, as
well as meet the changes and challenges being imposed upon them by Congress and private
insurers." With the establishment of a voluntary compliance program and a designated
hospital compliance officer, hospitals will be able improve the quality of patient care,
substantially reduce fraud, waste and abuse, and reduce the cost of healthcare to federal, state
and private health insurers.
Elements of a Compliance Program include:
I. Establish compliance standards, procedures and policies
II. Assign oversight responsibility for compliance to an individual high in the organization's
structure (i.e., dedicated compliance officer and a compliance committee)
III. Screening and evaluation of employees, physicians, vendors
IV. Communication, education and training on compliance issues
V. Monitoring, auditing and the establishment of internal reporting systems (e.g., anonymous
hotlines, email, etc.)
VI. Discipline for non-compliance
VII. Respond appropriately and immediately to detected offenses
What components of the establishment of compliance standards, procedures and
policies have an impact on Patient Access?
-Code of conduct
-Admission policy
-Discharge policy
-Patient referrals
, -Physician agreements
-Claim development
Name some special areas at high risk for non-compliance:
-Billing for items or services not rendered
-Providing medically unnecessary services
-Upcoding
-Outpatient services rendered in connection with inpatient stays
-Duplicate billing
-Unbundling
-Patients' freedom of choice
-Credit balances
Name some provisions of the The Patient Protection and Affordable Care Act
(PPACA):
-Ensure access to health insurance and protect against unaffordable out-of-pocket costs
-Tax credits established for low-income Americans
-Eliminating lifetime limits on benefits
-Provide assistance for those with pre-existing conditions
-Extend dependent coverage up to age 26
-Expand Medicaid coverage to more low-income Americans
-Reduce the prescription drug coverage gap ("donut hole") for those receiving the Medicare
Part D Prescription Drug Benefit. A whole title of the law focuses on Medicare reform.
-Require coverage of preventative services and immunizations
-Establish internet portals to assist with the identification of coverage options (e.g., The
Exchange)
