CHC EXAM UPDATED ACTUAL EXAM

@2025 Exam Material 1 CHC EXAM UPDATED ACTUAL EXAM QUESTIONS AND ANSWERS PASS GUARANTEED 100% 7 elements - Answer Policies & Procedures Oversight Responsibilities/Assignments Oversight Responsibilities/Due Care Education and Training Monitoring and Auditing Enforcement and Discipline Response and Prevention ECHO - Answer Economic, Clinical and Humanistic Outcomes Economic Outcomes - Answer Comparison between the cost of what was received and the benefit derived from alternatives Clinical Outcomes - Answer Changes to moribity/mortality rates as a result of healthcare intervention Humanistic Outcomes - Answer Psychological consequences of healthcare which include patient measures of functional status, quality of life and satisfaction with care @2025 Exam Material 2 A formal system that assures that products or services meet the characteristics associated with excellence - Answer Quality Assurance Process of identifying/evaluating quality of patient care services to ensure that a predetermined standard is being met - Answer QA Based on the assumption that quality can never be completely assured - a sustained program for identifying opportunities is necessary - Answer Quality Improvement Continuously improve the ability of all processes to meet the needs of customers - Answer QI Proactive, positive - Answer QI Reactive - focus on negative (look/find errors/correct) - Answer QA HMO, PPO, EPO - Answer Managed Care Organizations How do you determine the effectiveness of compliance education and training? - Answer Program evaluation summaries; post-tests; and internal and external monitoring and evaluation A relative value assigned to a diagnosis related group of patients in a medical care environment - Answer Case Mix INdex What is the case mix index used for? - Answer To determine the allocation of resources to care for and/or treat the patients in a group. @2025 Exam Material 3 Groups having the same condition based on main and secondary diagnosis, procedures and age, complexity and needs - Answer Diagnosis Related Groups (DRG) or Resource Use Groups (RUG) What has a relative average value assigned to it that indicates the amount of resources required to treat patients in a group, as compared to all of the other diagnosis-related groups within the system? - Answer DRG What does the CMI of a hospital reflect? - Answer The diversity, clinical complexity and needs for resources in the population of all patients in the hospital EMTALA - Answer Emergency Medical Treatment and Labor Act What does EMTALA Require? - Answer EDs to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies, regardless of health insurance status or ability to pay What is EMTALA a part of? - Answer COBRA What is EMTALA designed to prevent? - Answer To prevent hospitals from refusing to see or transferring financially undesirable patients to public hospitals without, at a minimum, providing a medical screening examination and treatment to ensure they are stable for transfer. What are the CMPs for hospitals and physicians who violate EMTALA? - Answer $50,000 per violation What is another penalty of violating EMTALA besides CMPs? - Answer Threat of Medicare decertification @2025 Exam Material 4 Any individual who comes and requests exam or treatment of a medical condition must receive a medical screening exam to determine whether an emergency medical condition exists. If an emergency medical condition exits, treatment must be provided until it is resolved or stabilized Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions. - Answer EMTALA Objectives When is a patient considered stable for transfer under EMTALA? - Answer IF the treating physician determines that no material deterioration is reasonably likely to occur during or as a result of the transfer between facilities. If a patient is unstable, can the hospital transfer the patient under EMTALA? - Answer Only if one of the two below: A physician certifies the medical benefits expected from the transfer outweigh the risks A patient makes a transfer request in writing after being informed of the hospital's obligations under EMTALA and the risks of transfer. Who has enforcement powers under EMTALA for violations? - Answer CMS - Hospitals OIG - Hospitals and Physicians What penalties may be assessed under EMTALA? - Answer Termination of hospital/physician's Medicare provider agreement Hospital fines up to $50,000 per violation ($25,000 for a hospital with fewer than 100 beds) @2025 Exam Material 5 Physician fines up to $50,000 per violation, including on-call physicians The hospital may be sued for personal injury in civil court under a private cause of action AKS - Answer Anti-Kickback Statute What is the AKS - Answer It prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate Federal health care program business Under AKS, what constitutes a referral? - Answer Referral from/to anyone Under AKS, what items or services are included? - Answer Any item or service Under AKS, what constitutes intent? - Answer Intent must be proven (knowing and willful) Under AKS, are there civil, criminal or civil and criminal penalties? - Answer Civil and Criminal Fines up to $25,000 per violation Up to 5 year prison term per violation - Answer AKS criminal penalties False Claims Act Liability Civil monetary penalties and program exclusion Potential $50,000 CMP per violation Civil assessment of up to three times amount of kickback - Answer What are the civil penalties under AKS? @2025 Exam Material 6 What are exceptions to AKS? - Answer Voluntary safe harbors What federal health care programs does AKS apply to? - Answer All federal health care programs Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship, unless an exception applies. Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibitted referral. - Answer Stark Law What items/services are covered under Stark? - Answer Designated health services. What referrals are covered under Stark? - Answer Referrals from a physician. What intent is required under Stark? - Answer No intent standard for overpayment (strict liability) Intent required for civil monetary penalties for knowing violations What type of penalties are involved with Stark? - Answer Civil Overpayment/refund obligation False Claims Act liability @2025 Exam Material 7 Civil monetary penalties and program exclusion for knowing violations Potential $15,000 CMP for each service Civil assessment of up to three times the amount claimed - Answer Stark civil penalties What exceptions are included under Stark? - Answer Mandatory exceptions What federal health care programs are included under Stark? - Answer Medicare/Medicaid Clinical Laboratory Services Physical Therapy Services Occupational Therapy Services Outpatient speech-language pathology services Radiology services Radiation therapy services and supplies DME and supplies Parenteral and enteral nutrients, equipment and supplies Prosthetics Orthotics Prosthetic devices and supplies Home health services Outpatient prescription drugs Inpatient and outpatient hospital services - Answer Examples of designated health services (DHS) @2025 Exam Material 8 Any person who knowingly submitted false claims to the government is liable the government's damages plus a penalty for each false claim - Answer FCA How many times the damages can one be penalized for under the FCA? - Answer Treble damages What do FCA civil penalties range from? - Answer $5,000 to $10,000 and treble the amount of the government's damage Why was the FCA originally enacted? - Answer Due to concern that suppliers of goods to the Union Army during the Civil War were defrauding the army Knowingly submit a false claim to the government Cause another to submit a false claim to the government Knowingly make a false record or statement to get a false claim paid by the government - Answer Three ways to be liable under the FCA What is a reverse false claim? - Answer Attempting to avoid having to pay money to the government. If a person who has violated the FCA reports the violation to the government (under certain conditions) what does the FCA provide that person shall be liable for? - Answer Not less than double damages. Does a person violate the FCA by simply submitting a false claim? - Answer No. They must have submitted it with knowledge of the falsity. @2025 Exam Material 9 What is knowledge of false information defined as under the FCA? - Answer Actual knowledge Deliberate ignorance of the truth or falsity of the information Reckless disregard of the truth or falsity of the information A demand for money or property made directly to the federal government or to a contractor, grantee, or other recipient if the money is to be spent on the government's behalf and if the federal government provides any of the money demanded or if the federal government will reimburse the contractor or grantee. - Answer Definition of a claim under FCA What allows private persons to file suit for violations on behalf of the government? - Answer FCA What is a suit filed by an individual on behalf of the government called? - Answer Qui Tam What is the person bringing the suit on behalf of the government called? - Answer Relator Who has primary responsibility for prosecuting the action if the government intervenes in a qui tam? - Answer The government What is the relator entitled to receive if the government intervenes in a qui tam action? - Answer Between 15-25% of the amount recovered by the government through the qui tam action. What is the relator's share if the government declines to intervene in the action? - Answer 25-30% The relator was convicted of criminal conduct arising from his or her role in the FCA violation @2025 Exam Material 10 Another qui tam concerning the same conduct has already been filed (known as the first to file bar) The government already is a party to a civil or administrative money proceeding concerning the same conduct. The qui tam action is based upon information that has been disclosed to the public through any of several means: criminal, civil or administrative hearings in which the government is a party, government hearings, audits, reports, or investigations or through the news media. - Answer Circumstances preventing a relator from filing a claim under the FCA With respect to information, a person: Has actual knowledge of the information Acts in deliberate ignorance of the truth of falsity of the information Acts in reckless disregard of the truth or falsity of the information - Answer Knowing/Knowingly under FCA Do the terms knowing and knowingly, under the FCA, require proof of specific intent to defraud? - Answer No More than 6 years after the date on which the violation is committed More than 3 years after the date when facts material to the right of action are known or reasonably should have been known by the official of the United States charged with responsibility to act in the circumstances, but in no event more than 10 years after the date on @2025 Exam Material 11 which the violation is committed, whichever occurs last. - Answer FCA civil action cannot be brought An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. - Answer Sentinel Event Legislation that established a new set of standards for corporate responsibility to protect shareholders and the general public from accounting errors and fraudulent practices in enterprises and to improve the accuracy of corporate disclosures. - Answer Sarbanes Oxley Act Accidents waiting to happen - Answer Latent errors When a hospital official notes that most errors are occurring at the sharp end, she means that.... - Answer The errors are occuring during interactions between caregivers and patients The majority of fraud and abuse violations relate to irregularities in - Answer Billing What group may request information from the Healthcare Integrity and Protection Data Bank? - Answer Quality improvement organizations HIPDB - Answer Healthcare Integrity and Protection Data Bank What was the HIPDB established by? - Answer HIPAA What is the goal of the HIPDB? - Answer To help combat fraud and abuse. @2025 Exam Material 12 Is the HIPDB operational today? - Answer No Information previously collected and disclosed by the HIPDB is now collected and disclosed by? - Answer National Practitioner Data Bank (NPDB) Why does the Healthcare Quality Improvement Act provide confidentiality and legal immunity for health care peer review processes? - Answer To encourage participation by physicians Audit conducted after a patient's discharge, after payment has been received. An income statement is an example - this would be money already received after the occurrence. - Answer Retrospective Audit Preliminary assessment that establishes a reference point. - Answer Baseline Audit A systematic and timely examination of financial transactions on a regular basis to ensure accuracy, authenticity, compliance with procedures and guidelines. - Answer Concurrent Audit An audit of information at a particular point in time - Answer Snapshot Audit What is CPOE - Answer Computerized Provider Order Entry After implementing CPOE, what do hospitals almost always see a decline in? - Answer Medication errors In the Current Procedural Terminology code set, Category II codes are for..... - Answer Evaluation and Management (e/m) @2025 Exam Material 13 The legal doctrine that assigns responsibility to a doctor for the behavior of his or her employee - Answer Res ipsa loquitor What does FMEA stand for? - Answer Failure Mode and Effects Analysis A structured way to identify and address potential problems, or failures and their resulting effects on the system or process before an adverse event occurs. - Answer FMEA What does RCA stand for? - Answer Root cause analysis A structured way to address problems after they occur - Answer RCA Involves identifying and eliminating process failures for the purpose of preventing an undesirable event - Answer FMEA In general, how may steps should a FMEA proceed in each direction? - Answer One Mandates that companies with securities listed in the US abide by generally accepted accounting practices - Answer Foreign Corrupt Practices Act The unethical practice of billing for a more expensive service than is actually provided - Answer DRG creep Is incarceration a possible punishment for a violation of the Stark Law? - Answer No Research suggests that people make fewer errors when they.... - Answer work in a team @2025 Exam Material 14 What group reports information to the HIPDB? - Answer Peer review organizations The earliest point at which a successor event may follow a prerequisite event in program evaluation and review technique is called the.... - Answer lag time Obligations to the Public Obligations to the employing organization Obligations to the Profession - Answer Three categories of obligations outlined in the Code of Ethics for Healthcare Compliance Professionals issued by the HCCA Are physician services covered by the Stark Law? - Answer No - DHS only Compliance procedures such as education for employees need to include policies focusing on the topics to be covered, the materials that are included, and the presentation formats to be used. Which out of the below listing is not accurately defined? 1. Computer based learning sessions are professionally provided, easily designed for the specific education needs of a particular facility and provide easy scheduling for employees. 2. Written self study is generally utilized for specialized training sessions with professional prepared materials and give the employees scheduling flexibility and high reproducibility. 3. Educational training sessions using case studies are the most effective formats that are used in compliance education, but is the most difficult to prepare. 4. PowerPoint presentations are prepared in-house usually and are the most effective of the formats that are used for compliance education, and it i - Answer PowerPoint presentations are prepared in-house usually and are the most effective of the formats that are used for compliance education, and it is the easiest to prepare. @2025 Exam Material 15 Which is not an element needed in the compliance program pursuant to the Federal Sentencing Guidelines? Trustworthy individuals Education Monitoring and Auditing Marketing and Management - Answer Marketing and management What basic component is associated with a specific body of law that an organization must comply with? It's a basic compliance program component. - Answer Substantive component When looking into what goals for a compliance work plan are, what best describes goals? Long in nature Generic to all companies Very specific General in nature - Answer General in nature Which of the assessments listed below will not determine the effectiveness of the existing compliance staff? Work plan should be reviewed and any delays in tasks should be noted. @2025 Exam Material 16 Results of evaluations and screenings should be reviewed by the CC Determine the number of employees that are needed to adequately address risk Insure that all compliance P&Ps are being implemented and followed - Answer Results of evaluations and screenings should be reviewed by the CC Which of the forms of assessment below is not related to the screening of employees? Performing an audit of HR files to insure they contain documentation of pre-hire screening occurring before the employee's first day of work. Reviewing all employment applications to insure that each screening type was performed using "data mining" processes using lists from other states, and using any other names of the applicants. Audit the employee files to insure that all documentation in regards to employee education that is based on the importance of current licenses and certifications, and of exclusions. Reviewing all employment applications to insure that all documentation pertaining to the applicant's immediate family member screenings have been performed. - Answer Reviewing all employment applications to insure that all documentation pertaining to the applicant's immediate family member screenings have been performed. Which of the following is not a recommended way for the compliance team to ensure that a culture of compliance process is being performed? By surveying the employees/agents in their opinions and knowledge of the program @2025 Exam Material 17 By reviewing the results of the auditing processes and determining the amount of violations due to lack of communication. By reviewing the communication documentation such as records of emails, posters and education materials By reviewing the incentives and rewards that are used to ensure the compliance program knowledge. - Answer By reviewing the results of the auditing processes and determining the amount of violations due to lack of communication. Which of the methods listed below is not a tool to monitor the training plan and its use? Insure that the policy requiring employee/agent training occurs is periodically reviewed and revised when appropriate. Review the training plan periodically to ensure that it is properly developed, used, and revised when appropriate Review the training sessions sign-in sheet to ensure that all required employees/agents are attending the necessary sessions. Ensure that the training plan contains required training, expected audience, topics to be covered and methods of delivery. - Answer Insure that the policy requiring employee/agent training occurs is periodically reviewed and revised when appropriate. A noncompliance hotline is also referred to as? Whistleblower hotline Community hotline Reward Hotline @2025 Exam Material 18 Counseling hotline - Answer Whistleblower hotline There are several differences between the requirements of the auditing and the monitoring procedures of a compliance program. Which of the below is not accurate of these two compliance areas? Auditing is required in instances of the Sarbanes-Oxley Act and is otherwise conducted according to the compliance program's policies and procedures. Monitoring policies are designed under the standards and requirements of regulations such as Stark, HIPAA, Code of Ethics, etc. Monitoring processes are usually conducted by the management, and in turn reported to the compliance department. Auditing policies are designed under the standards and requirements of regulations such as Stark, HIPAA, Code of Ethics, etc. - Answer Auditing policies are designed under the standards and requirements of regulations such as Stark, HIPAA, Code of Ethics, etc. Which of the reasons below is the cause of most of the violations and sanctions related to compliance programs and sanctions by the OIG and other governmental agencies? Documentation/reporting errors that should have been caught during monitoring efforts Whistleblowers Errors in coding and billing of the patient's EHRs due to the translation of records from one code to another @2025 Exam Material 19 Lack of compliance program issues, such as inefficient policies and procedures in high risk areas such as filing claims. - Answer Whistleblowers Which of the following best describes a compliance risk assessment step associated with performing an analysis of the hospital's weaknesses, strengths, and threats? Identify relevant business objectives. Identify events that can affect objectives from being achieved Assess residual impact of the risks Evaluate the portfolio of the risk and determine what the risk responses will be. - Answer Identify relevant business objectives A compliance team is examining risks. What would help determine risks to audit? Create a flow chart Vote Use the same risks as last year Look at external benchmarks - Answer Create a flow chart Internal reports help in which of the following ways? Help with planning, discipline, correcting and evaluating. Help with planning, evaluating and customer service. @2025 Exam Material 20 Help with planning, evaluating and controlling. Help with planning, evaluating, controlling and customer service. - Answer Help with planning, evaluating and controlling A hospital will be given how much warning time prior to an external audit occurring? - Answer Only days prior to the audit Revenue cycles have three areas that have been determined for risk of non-compliance, which of the areas listed below is not included? Pre-arrival activities (front end processes) - scheduling, registration, admittance Episode of care activities (middle processes) - management of patient care and patient case management procedures Back End processes - coding and billing, reimburse claims to government health care programs, transcription of patient records Patient account processes, such as billing and collection (back end), such as write offs and adjustments to billing and handling patient complaints. - Answer Back End processes - coding and billing, reimburse claims to government health care programs, transcription of patient records Which of the below is true of a willful neglect but violation is corrected within the required time period HIPAA violation penalty? Min $3,000/violation @2025 Exam Material 21 Min $7,000/violation Min $10,000/violation Min $14,000/violation - Answer Min $10,000/violation Which of the below is true of a reasonable cause HIPAA violation penalty? Min $500/violation Min $1,000/violation Min $1,500/violation Min $2,000/violation - Answer Min $1,000/violation Which of the statements listed below is not correct with regard to the should nots of writing an investigative interview memo? Should not include any judgments that are based on regulations, laws or legal issues Not omit any hand written notes of the interviewer's, documents that were collected prior to the interview, etc. Not omit any significant occurrences of the interview, such as if the interviewee cried, shouted or stormed out of the room Should not express any opinions, this could later be reviewed as negative or possibly affect an employee's reputation. - Answer Not omit any hand written notes of the interviewer's, documents that were collected prior to the interview, etc. What is another name for the principled negotiation tool? - Answer Integrative negotiations @2025 Exam Material 22 Out of the below, what does a compliance professional need to ensure is in the investigative report? Non-involved employee feedback and opinions Description of the nature of the allegation Projected cost of the investigation Personal information about the reporter - Answer Description of the nature of the allegation True or False: Employees have the right to refuse to give testimony that is incriminating - Answer True Which of the events below is not considered a breach of security? When after disclosure of the information, the employee reports the information to the compliance team and immediately discloses the violation. The patients' health information is accessed or acquired, unintentionally, by an employee or agent of the organization, under the authority of the hospital When after disclosure of the information, the impermissible employee cannot retain the information, like in conversation. The patients' health information is accessed or acquired, unintentionally, through disclosure by any employee to another employee, both under the authority of the hospital. - Answer When @2025 Exam Material 23 after disclosure of the information, the employee reports the information to the compliance team and immediately discloses the violation. A hospital certifies compliance with a prescribed program while at the same time knowing that an undisclosed infraction has already occurred. What would not occur? The hospital may not be sanctioned or excluded at this time, but should immediately perform an audit. The hospital may have committed a second infraction of filing a false statement. The hospital may be at risk of loosing state certifications and/or licensure. The hospital may be banned from federal healthcare programs such as Medicare. - Answer The hospital may not be sanctioned or excluded at this time, but should immediately perform an audit. Approvals, authorizations and verifications are examples of which type of internal controls? - Answer Preventative What basic component of compliance programs includes laws related to Medicaid, insurance, ERISA, antitrust and tax? - Answer Substantive component Objectives to be accomplished in approximately 6-8 months are what kind of objectives? - Answer Middle Term What basic component of the compliance program includes areas of high level oversight, reporting, and employee screening? - Answer Structural component There are approximately how many OIG exclusion lists? - Answer 35 What type of training involves coaching and lecturing multiple employees at once at the hospital? - Answer Onsite training/Online training @2025 Exam Material 24 What training technique most closley fits the description of being effective for teaching new procedures, being immediately applicable and allowing the trainer to immediately determine if the employee has learned the material? - Answer Hands on training Which of the recommendations below is not suggested to maintaining open lines of communication between the compliance department and the employees/agents of an organization? Interview employees re: their knowledge of the compliance employees' compliance knowledge and competencies Conduct periodic interview and check-in meetings with employees in regard to perception of accessibility of compliance employees Interview employees regarding their knowledge of the reporting violations or non-compliance risks, and the P&Ps associated with reporting. Conduct periodic interview and check in meetings with employees in regarding to whether their personal compliance concerns are taken seriously by the compliance employees. - Answer Interview employees re: their knowledge of the compliance employees' compliance knowledge and competencies What type of risk assessment categorizes risk on a nominal scale? - Answer Qualitative risk assessment. Should a compliance professional notify all staff or only top level staff of a HIPAA compliance audit? - Answer All staff @2025 Exam Material 25 Which of the below is not effective in assessing the effectiveness of an educational sessions? Review the post educational session's employee evaluation and testing to determine the effectiveness of the materials presented. Review/track the testing results of the employee's education sessions to determine any particular high risk areas that are not already known. Document and review and changes or modifications that are made to the educational programs and materials that are made in response to testing results. Document and review any employee survey results that have been collected in regards to the compliance culture of the workplace. - Answer Document and review any employee survey results that have been collected in regards to the compliance culture of the workplace. What are internal reports based on? - Answer Facts What will help ensure that a compliance officer's open-door policy is followed? Hold office hours Survey employees Track number of reports heard Advertise the policy - Answer Track number of reports heard All of the below listed policies are recommended as monitoring procedures policies except: Periodic interviews with employees and agents that are involved in management, coding and billing, patient care, etc. to determine opinions on the program. @2025 Exam Material 26 Annual audits of the medical and financial records that are focused on the Medicare reimbursement and cost reports. Solicit impressions from employees focused on their job duties and their experiences in the facility, in the form of surveys, questionnaires, etc. Periodic reviews of the compliance program, its P&Ps in relation to the changing regulations. - Answer Solicit impressions from employees focused on their job duties and their experiences in the facility, in the form of surveys, questionnaires, etc. To identify the cause of issues and provide recommendations on ways to fix/prevent the violations - Answer Reasons why a compliance audit is used What is the maximum prison penalty for criminal HIPAA violations? - Answer 10 years What type of negotiations are also referred to as interest based negotiations? - Answer Integrative negotiations Is a listing of the employees interviewed during an investigation and the documents collected required to be placed in the final report prepared for presentation to the Board? - Answer No CLIA - Answer Clinical Laboratory Improvement Amendments Each specific laboratory system, assay, examination is graded for level of complexity by assigning scores of 1, 2 or 3 - Answer CLIA CLICA Score 1 is the highest or lowest level of complexity? - Answer Lowest @2025 Exam Material 27 Knowledge Training and Experience Reagents and Materials Preparation Characteristics of Operational Steps Callibration, quality control and proficiency testing materials Test System troubleshooting and equipment maintenance Interpretation and judgment - Answer CLIA Criteria for Categorization Who has the primary responsibility for the operation of the CLIA program? - Answer CMS Center for Medicaid and State Operations Survey and Certification Group Division of Laboratory Services - Answer Responsible for implementation of the CLIA program Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist - Answer FCA Knowingly soliciting, receiving, offering and/or paying remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs - Answer AKS Making prohibited referrals for certain DHS - Answer Stark True/False: No proof of specific intent to defraud is required to violate the FCA. - Answer True @2025 Exam Material 28 A physician knowingly submits claim to Medicare for a higher level of medical services than actually provided or higher than the medical record documents - Answer FCA A provider receives cash or below FMV rent for medical office space in exchange for referrals - Answer AKS A provider refers a beneficiary for a DSH to a business in which the provider has an investment interest - Answer Stark True/False: Excluded providers may not participate in federal health care programs for a designated period - Answer True True/False: With lots of exceptions, an excluded provider may not bill federal health care programs - Answer False Can an employer or group practice bill for an excluded provider's services? - Answer No Is reinstatement automatic at the end of an exclusion period? - Answer No The federal agency within the US Department of HHS that administers the Medicare, Medicaid, SCHIP, CLIA and several other health-related programs. - Answer CMS Help calculate the Medicare fee-for-service (FFS) improper payment rate by reviewing claims to determine if they were paid properly - Answer CERT Contractors (Comprehensive Error Rate Testing Contractors) Process claims and roll providers and suppliers - Answer MACs (Medicare Administrative Contractors) @2025 Exam Material 29 Monitor fraud, waste and abuse in the Medicare Parts C and D Programs - Answer MEDICs (Medicare Drug Integrity Contractors) Reduce improper payments by detecting and collecting overpayments and identifying underpayments - Answer Recovery Audit Program/Recovery Auditors Investigate potential fraud, waste and abuse for Medicare Parts A and B; DME prosthetics, orthotics and supplies; and Home Health and Hospice - Answer ZPICs (Zone Program Integrity Contractors) (formerly called Program Safeguard Contractors PSCs) Combine and integrate functions of Medicare and Medicaid Program Integrity audit and investigation work into a single contract. - Answer UPIC (Unified Program Integrity Contractor) A national effort launched by HHS and CMS - a state of the art predictive analytics technology that runs predictive algorithms and other analytics nationwide on all Medicare FFS claims prior to payment to detect potentially suspicious claims and patterns that may constitute fraud and/or abuse. - Answer Fraud Prevention System (FPS) What did the GSA consolidate several Federal procurement systems into? - Answer The System Award Management (SAM) What information on entities does SAM include? - Answer Debarred or proposed for debarment Disqualified from certain types of Federal financial/non-financial assistance and benefits Disqualified from receiving Federal contracts or certain subcontracts Excluded Suspended @2025 Exam Material 30 AKS Safe Harbors - Answer Bone Fide Employment Relationship Personal Service Arrangements Lease or Rental of Office Space or Equipment Referral Services (as long as equal to all others) Group Purchasing Organizations Other safe harbor provisions under AKS applying to transactions and relationships include: - Answer Discounts Investment interests Management contracts Practitioner recruitment Price reductions Sale of health care practice Waivers of copayments, coinsurance and deductibles Warranties Criminal penalties include fines of up to $25,000 and five year's imprisonment - Answer AKS OIG can pursue civil penalties of up to $50,000 per violation plus three times the amount of any government overpayment. - Answer AKS Exclusively a civil enforcement statute - Answer Stark This law is narrower - limited only to DHS paid for by Medicare - Answer Stark Element of intent is required for a violation - Answer AKS @2025 Exam Material 31 Strict liability statute - no intent required - Answer Stark Applies to any referral source, i.e., not just physicians - Answer AKS Violation must involve a referral relationship between a physician and an entity - Answer Stark Hospital must not later claim the amount reduced/waived as bad debt Hospital must offer to reduce/waive the coinsurance or deductible amounts Hospital's offer to reduce/waive coinsurance deductible amount must not be made as part of a price reduction agreement between a hospital and a third-party payer unless the agreement is part of a contract for furnishing of items/services to a beneficiary of a Medicare supplemental policy - Answer AKS Safe Harbor for Reduction/Waiver of a federal or state health program beneficiary's obligation to pay coinsurance or deductible amounts Buyer must fully and accurately report any price reduction of an item (including free items) obtained as part of a warranty in the applicable cost reporting mechanism or claim for payment filed with the department or a state agency Manufacturer/supplier must fully and accurately report the price reduction of the item on the invoice or statement submitted to the buyer and inform the buyer of its obligations Manufacturer/supplier must not pay any remuneration to any individual other than a beneficiary or entity for any medical, surgical or hospital expense incurred by a beneficiary other than for the cost of the item itself. - Answer AKS Safe Harbor for Any Payment or @2025 Exam Material 32 Exchange of Anything of Value Under a Warranty Provided by a manufacturer/supplier of an item to a buyer Arrangement is set out in writing, is signed by the parties, and specifies the services covered by the arrangement Aggregate services contracted for do not exceed those that are reasonable and necessary for the legitimate business purposes of the arrangement. Arrangement term is at least 1 year. Compensation to be paid is set in advance, does not exceed FMV and is not determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties (excluding physician incentive plans) Services furnished do not violate any federal or state law. Holdover personal service arrangement for up to 6 months following the expiration of an agreement of at least 1 year that met all of the above conditions - Answer Stark exception to the referral prohibition related to compensation arrangements for personal services or management. The agency agreement covers all of the services the agent provides for the term of the agreement and specifies the services to be provided. Agreement specifies the exact schedule of services (if not full time) Agreement term is not less than 1 year @2025 Exam Material 33 Aggregate compensation paid over the term of the agreement is set in advance, is consistent with FMV in arms-length transactions and is not determined in a manner that takes into account the volume or value of any referrals or business otherwise generated between the parties for which payment may be made in whole or in part under Medicare or a state health care program. Services performed do not violate any federal or state law. Services contracted for do not exceed those which are reasonably necessary to accomplish the commercially reasonable business purpose of the services - Answer AKS Safe Harbor for remuneration from an entity under a personal service arrangement or management contract. Period from the date of the first agreement pertaining to the sale to the completion of the sale is not more than 1 year. Practitioner selling practice will not be in a professional position to make referrals to, or otherwise generate business for, the purchasing practitioner for which payment may be made in whole or in part under Medicare or a state health care program after 1 year from the date of the first agreement pertaining to the sale. Remuneration does not include any payment made to a practitioner by a hospital or other entity where the practitioner is selling his or her practice to the hospital or other entity so long as: The period from the date of the first agreement pertaining to the sale to the completion of the sale is not more than 3 years The practitioner selling the business will not be in a professional position after completion of the sale to make or influence referrals/generate business for t - Answer AKS Safe Harbor for payments made to a practitioner by another practitioner where first practitioner is selling a practice to the second practitioner @2025 Exam Material 34 Remuneration that meets all of the conditions of the AKS safe harbor for referral services - Answer Stark exception to the referral prohibition related to compensation arrangements for referral services Referral service does not exclude as a participant in the referral service any individual/entity who meets the qualifications for participation Any payment the participant makes to the referral service is assessed equally against and collected equally from all participants and is only based on the cost of operating the referral service and not on the volume or value of any referrals to or business otherwise generated by either party for the other party The referral service imposes no requirements on the manner in which the participant provides services to a referred person (except to charge at the same rate as it charges other persons not referred by the referral service). The referral service discloses: The manner in which it selects the group of participants in the referral service Whether the participant has paid a fee to the referral service The manner in which it selects a particular participant from this gro - Answer AKS Safe Harbor for payments between an individual/entity and another entity serving as a referral source. Home health coverage criteria include that the beneficiary must..... - Answer be homebound, require skilled services and be under the care of a physician When an investigator presents to a facility with a search warrant, the FIRST thing an employee should do is: @2025 Exam Material 35 Verify the investigator's credentials Request a copy of the warrant Call the compliance professional Notify the Chair of the Board - Answer Verify the investigator's credentials