COMPLIANCE 101 QUESTIONS AND
ANSWERS WITH SOLUTIONS 2024
compliance program - ANSWER prevention, detection, collaboration, and enforcement
Effective compliance program - ANSWER must be an ongoing process and commitment to an ethical way
of conducting business
Office of Inspector General and Justice Department - ANSWER is responsible for enforcing the rules and
regulations under the Medicare and Medicaid laws outline as part of the SSA by CMS.
Benefits of compliance program addressed by OIG - ANSWER safeguards the organizations' legal
responsibility to abide by applicable laws and regulations.
Corporate Integrity Agreement (CIA) - ANSWER government imposed compliance program
Why compliance programs are essential - ANSWER prevent paybacks, probation, government designed
programs, exclusion, reduce threat of lawsuits from whistleblowers (qui tam).
OIG Top 10 reasons to implement a compliance program - ANSWER demonstrates a strong commitment
to honesty and responsible corporate relations, reinforces employees sense of right and wrong, fulfill
legal duty to payers, cost effective, more accurate view of what is going on, quality of care to clients,
provides procedures to promptly correct misconduct, mitigate any sanction imposed by government.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - ANSWER a criminal offense to
submit claims based on incorrect codes or medically unnecessary services, and government has the
power to exclude an organization from Medicare/caid and other govt programs.
Balanced Budget Act of 1997 - ANSWER three strikes and your out clause , requiring permanent
expulsion if found guilty of fraud a third time.
False Claims Act (FCA) - ANSWER empowers the govt to investigate and bring civil action in fraud cases.
Implemented in Civil War to control price gouging.
, Qui tam - ANSWER is a whistleblower who brings the fraud to light.
A whistleblower can receive a % of the govt's total award - ANSWER 15-25% if DOJ assumes the case or
25-30% if DOJ declines
To avoid lengthy and expensive litigation, an organization can negotiate a ____________with the govt
admits no fault or liability but does submit to a govt plan for corrective action. - ANSWER CIA
Length of CIAs - ANSWER 3-5 yrs with some lasting up to 8 yrs
1984 Congress enacted Sentencing reform act which includes FSG - ANSWER act designed to correct
inequities in federal sentencing and give guidance for assessing fines and methods for calculation of
culpability score.
The culpability score - ANSWER calculation of the degree of blame or guilt used to determine fines,
restitution, forfeiture, and probation.
If an upper level employee has participated in or was willfully ignorant of an offense, - ANSWER the
likelihood of culpability score will be increased.
If an organization reports a violation promptly, - ANSWER the culpability score may be mitigated.
An aggravating factor in FSG - ANSWER is that the organization has had a repeated offense
A mitigating factor for FSG - ANSWER is that the organization cooperated with the govt investigators
2010 FSG amendment changes includes way to further reduce culpability scores: - ANSWER C&E
program has responsibility- to report directly to board or appropriate subgroup, to detected offense
before external discovery, prompt reporting, no one with OP responsibility participated in, condoned, or
was willfully ignorant of the offense.
ANSWERS WITH SOLUTIONS 2024
compliance program - ANSWER prevention, detection, collaboration, and enforcement
Effective compliance program - ANSWER must be an ongoing process and commitment to an ethical way
of conducting business
Office of Inspector General and Justice Department - ANSWER is responsible for enforcing the rules and
regulations under the Medicare and Medicaid laws outline as part of the SSA by CMS.
Benefits of compliance program addressed by OIG - ANSWER safeguards the organizations' legal
responsibility to abide by applicable laws and regulations.
Corporate Integrity Agreement (CIA) - ANSWER government imposed compliance program
Why compliance programs are essential - ANSWER prevent paybacks, probation, government designed
programs, exclusion, reduce threat of lawsuits from whistleblowers (qui tam).
OIG Top 10 reasons to implement a compliance program - ANSWER demonstrates a strong commitment
to honesty and responsible corporate relations, reinforces employees sense of right and wrong, fulfill
legal duty to payers, cost effective, more accurate view of what is going on, quality of care to clients,
provides procedures to promptly correct misconduct, mitigate any sanction imposed by government.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) - ANSWER a criminal offense to
submit claims based on incorrect codes or medically unnecessary services, and government has the
power to exclude an organization from Medicare/caid and other govt programs.
Balanced Budget Act of 1997 - ANSWER three strikes and your out clause , requiring permanent
expulsion if found guilty of fraud a third time.
False Claims Act (FCA) - ANSWER empowers the govt to investigate and bring civil action in fraud cases.
Implemented in Civil War to control price gouging.
, Qui tam - ANSWER is a whistleblower who brings the fraud to light.
A whistleblower can receive a % of the govt's total award - ANSWER 15-25% if DOJ assumes the case or
25-30% if DOJ declines
To avoid lengthy and expensive litigation, an organization can negotiate a ____________with the govt
admits no fault or liability but does submit to a govt plan for corrective action. - ANSWER CIA
Length of CIAs - ANSWER 3-5 yrs with some lasting up to 8 yrs
1984 Congress enacted Sentencing reform act which includes FSG - ANSWER act designed to correct
inequities in federal sentencing and give guidance for assessing fines and methods for calculation of
culpability score.
The culpability score - ANSWER calculation of the degree of blame or guilt used to determine fines,
restitution, forfeiture, and probation.
If an upper level employee has participated in or was willfully ignorant of an offense, - ANSWER the
likelihood of culpability score will be increased.
If an organization reports a violation promptly, - ANSWER the culpability score may be mitigated.
An aggravating factor in FSG - ANSWER is that the organization has had a repeated offense
A mitigating factor for FSG - ANSWER is that the organization cooperated with the govt investigators
2010 FSG amendment changes includes way to further reduce culpability scores: - ANSWER C&E
program has responsibility- to report directly to board or appropriate subgroup, to detected offense
before external discovery, prompt reporting, no one with OP responsibility participated in, condoned, or
was willfully ignorant of the offense.
