HCCA - CHC Study Questions (MASTER FLASHCARDS)

HCCA - CHC Study Questions (MASTER FLASHCARDS) 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). Ans- True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) Ans- 1.Protect our programs 2.Protect your patients 3.Protect the Provider #:~:text=Proper%20documentation%2C%20both%20in%20patients,to%20protect%20you%20t he%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 d. fourth level of appeal Ans- 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 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. Ans- 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 Compliance Program? a. continuous training and improvements b. effective reporting path c. non-retaliation for whistleblowers d. reliable and equal discipline Ans- c. non-retaliation for whistleblowers 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 Ans- 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 Ans- 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 Ans- 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. Ans- 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 federal required actions or standards. a. CAP b. Procedure document c. Policy document d. Legal standards Ans- c. 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 Ans- Creation Use Maintenance Retention Disposition Standards of Conduct (written P&Ps) Ans- Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations Code of Conduct: Content Checklist Ans- • 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 Code of Conduct and Employees Ans- 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 Ans- • 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: Ans- • 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? Ans- 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 Ans- 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: 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? Ans- 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. Ans- 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 Ans- • 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: Ans- 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. • anonymous reporting and, • no retaliation or retribution for bringing forth problems/concerns Place to start with Enforcement is: Ans- Standards of conduct and P&Ps For Enforcement and Disciplinary Actions, Policies should include: Ans- 1. 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: Ans- OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? Ans- 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 Ans- 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. Ans- 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