SOPHOS CERTIFIED ENGINEER EXAM
QUESTIONS WITH 100 PERCENT CORRECT
ANSWERS VERIFIED FULL SOLUTION
GUIDE
⩥ Safe harbors under anti-kickback statute?
Answer: Safe harbors immunize certain payments and business practices
that are implicated by the anti-kickback statute from criminal and civil
prosecution under the statute to be protected in a safe harbor and
arrangement must fit squarely in the safe harbor
⩥ Examples of safe harbors
Answer: Safe harbors include investments in ambulatory surgical
centers, joint ventures in underserved areas, practitioner recruitment in
underserved areas, sales a physician practices to hospitals in underserved
areas, subsidiaries for obstetrical malpractice insurance in underserved
areas, investment in group practices, specialty referral arrangements
between providers, cooperative the hospital service organizations
⩥ Seven elements of program for individual and small group physician
practices
Answer: The seven elements are conducting internal monitoring and
auditing, implementing compliance and practice standards, designating a
compliance officer or contact, conducting appropriate training and
education, responding appropriately to detected offenses and developing
,corrective action, developing open lines of communication, and
enforcing disciplinary standards through well-publicized guidelines
⩥ Benefits of a voluntary compliance program
Answer: Speed and optimize proper payment of claims, minimize
mistakes, reduce the chances that an audit will be conducted by HCFA or
that OIG and, avoid conflicts with the self referral and anti-kickback
statute
⩥ Difference between erroneous and fraudulent claims to federal
healthcare programs
Answer: Fraudulent claims intentionally or recklessly are submitted to
federal healthcare programs. Erroneous claims are innocent errors
submitted unintentionally to federal healthcare programs
⩥ What responsibility do healthcare providers have to federal healthcare
programs?
Answer: Federal healthcare providers have a duty to reasonably ensure
that the claim submitted to Medicare and other federal healthcare
programs are true and accurate
⩥ What are the steps for auditing and monitoring evaluations
Answer: Ensure that the standards and procedures are in fact current and
accurate but also whether the compliance program is working. following
steps a standards and procedures review and claim submission audit
,⩥ What do you validate reviewing policies and procedures?
Answer: Validate they are current and accurate if standards and
procedures are found to be ineffective or outdated they should be
updated to reflect changes in government regulations or compendiums
generally relied upon by physicians and insurance for example CPT and
ICD-10 codes
⩥ Who should be involved in a claim submission audit?
Answer: The person in charge of billing and a medically trained person
to audit the records
⩥ What should physicians practice do if they are using another entities
compliance materials?
Answer: They need to tailor the materials to be applied by the physician
practice starting by the following, 1) develop written standards and
procedures 2) updating clinical forms 3) make sure they facilitate
encouraging clear and complete documentation of patient care
⩥ What are the four basic risk areas developed by the OIG?
Answer: 1) coding and billing 2) reasonable and necessary services 3)
documentation 4) improper inducements
⩥ What are the biggest risks with coding and billing?
, Answer: Billing for services not rendered or provided by as claimed,
submitting claims for equipment medical supplies and services that are
not reasonable and necessary, double billing resulting in duplicate
payments, billing for noncovered services as if covered, knowing misuse
of a provider identification numbers which results in improper billing,
unbundling billing for each component of service instead of billing for
all inclusive code, failure to properly use Coding modifiers, and a coding
the level of service provided
⩥ What are the risks with the physician documentation?
Answer: The risks are documentation is not performed timely and
accurate. it is incomplete, it does not reflect appropriate documentation
of the diagnosis and treatment plan
⩥ What are examples of internal documentation guidelines a practice
could use?
Answer: Examples of internal documentation guidelines are the medical
record is complete and legible, the documentation for each patient
encounter includes the reason for the encounter any relative history,
physical examination, findings prior to diagnostic test results,
assessment clinical impression or diagnosis plan of care and date of
legible Identity of the other observer
⩥ What is one method for improving quality in documentation?
Answer: The method is to compare the practices claim denial rate to the
rates of other practices in the same specialty to the extent of the practice
can obtain that information from the carrier. Physician coding and
QUESTIONS WITH 100 PERCENT CORRECT
ANSWERS VERIFIED FULL SOLUTION
GUIDE
⩥ Safe harbors under anti-kickback statute?
Answer: Safe harbors immunize certain payments and business practices
that are implicated by the anti-kickback statute from criminal and civil
prosecution under the statute to be protected in a safe harbor and
arrangement must fit squarely in the safe harbor
⩥ Examples of safe harbors
Answer: Safe harbors include investments in ambulatory surgical
centers, joint ventures in underserved areas, practitioner recruitment in
underserved areas, sales a physician practices to hospitals in underserved
areas, subsidiaries for obstetrical malpractice insurance in underserved
areas, investment in group practices, specialty referral arrangements
between providers, cooperative the hospital service organizations
⩥ Seven elements of program for individual and small group physician
practices
Answer: The seven elements are conducting internal monitoring and
auditing, implementing compliance and practice standards, designating a
compliance officer or contact, conducting appropriate training and
education, responding appropriately to detected offenses and developing
,corrective action, developing open lines of communication, and
enforcing disciplinary standards through well-publicized guidelines
⩥ Benefits of a voluntary compliance program
Answer: Speed and optimize proper payment of claims, minimize
mistakes, reduce the chances that an audit will be conducted by HCFA or
that OIG and, avoid conflicts with the self referral and anti-kickback
statute
⩥ Difference between erroneous and fraudulent claims to federal
healthcare programs
Answer: Fraudulent claims intentionally or recklessly are submitted to
federal healthcare programs. Erroneous claims are innocent errors
submitted unintentionally to federal healthcare programs
⩥ What responsibility do healthcare providers have to federal healthcare
programs?
Answer: Federal healthcare providers have a duty to reasonably ensure
that the claim submitted to Medicare and other federal healthcare
programs are true and accurate
⩥ What are the steps for auditing and monitoring evaluations
Answer: Ensure that the standards and procedures are in fact current and
accurate but also whether the compliance program is working. following
steps a standards and procedures review and claim submission audit
,⩥ What do you validate reviewing policies and procedures?
Answer: Validate they are current and accurate if standards and
procedures are found to be ineffective or outdated they should be
updated to reflect changes in government regulations or compendiums
generally relied upon by physicians and insurance for example CPT and
ICD-10 codes
⩥ Who should be involved in a claim submission audit?
Answer: The person in charge of billing and a medically trained person
to audit the records
⩥ What should physicians practice do if they are using another entities
compliance materials?
Answer: They need to tailor the materials to be applied by the physician
practice starting by the following, 1) develop written standards and
procedures 2) updating clinical forms 3) make sure they facilitate
encouraging clear and complete documentation of patient care
⩥ What are the four basic risk areas developed by the OIG?
Answer: 1) coding and billing 2) reasonable and necessary services 3)
documentation 4) improper inducements
⩥ What are the biggest risks with coding and billing?
, Answer: Billing for services not rendered or provided by as claimed,
submitting claims for equipment medical supplies and services that are
not reasonable and necessary, double billing resulting in duplicate
payments, billing for noncovered services as if covered, knowing misuse
of a provider identification numbers which results in improper billing,
unbundling billing for each component of service instead of billing for
all inclusive code, failure to properly use Coding modifiers, and a coding
the level of service provided
⩥ What are the risks with the physician documentation?
Answer: The risks are documentation is not performed timely and
accurate. it is incomplete, it does not reflect appropriate documentation
of the diagnosis and treatment plan
⩥ What are examples of internal documentation guidelines a practice
could use?
Answer: Examples of internal documentation guidelines are the medical
record is complete and legible, the documentation for each patient
encounter includes the reason for the encounter any relative history,
physical examination, findings prior to diagnostic test results,
assessment clinical impression or diagnosis plan of care and date of
legible Identity of the other observer
⩥ What is one method for improving quality in documentation?
Answer: The method is to compare the practices claim denial rate to the
rates of other practices in the same specialty to the extent of the practice
can obtain that information from the carrier. Physician coding and
