HCCA CHC Study Set questions and
answers
Deficit Reduction Act of 2005✔✔Requires that organizations receiving more than $5
million in Medicaid funds must provide education on the False Claims Act.
Corporate Integrity Agreement (CIA)✔✔A compliance program imposed by the
government, which involves substantial government oversight and outside expert
involvement in the organization's compliance activities and is generally required as a
condition of settling a fraud and abuse investigation. Negotiated primarily between
the OIG and the health care entity.
Seven Elements of a Compliance Program✔✔1. Standards of Conduct
2. Oversight & Resources
3. Education & Training
4. Auditing and Monitoring
5. Consistent and appropriate discipline
6. Reporting Processes
7. Response and Prevention of Problems
LEIE (List of Excluded Individuals)✔✔A list of individuals and organizations that are
excluded from participating/billing the federal healthcare program (i.e. Medicare).
This list is updated monthly and is the responsibility of the organization to check their
list of physicians, employees, etc. against this to prevent a violation of the False
Claims Act.
Medicare Cost Report✔✔A report that contains provider information such as facility
characteristics, utilization data, cost and charges by the cost center. If administrator's
or business associate pay appears on this that is excluded from the LEIE, it may be
liable as a FCA.
5 to 50 Years✔✔Mandatory Exclusion (felony) length
Up to 5 Years✔✔Permissive exclusion (misdemeanor) length
State Medicaid Exclusion List✔✔State Version of LEIE, also monitored monthly
False Claims Act✔✔Prohibits anyone from knowingly submitting or causing to be
submitted a false or fraudulent claim to the government.
Anti-Kickback Law✔✔Prohibits the solicitation, receiving, offering, or paying of any
remuneration directly or indirectly in cash or in kind in exchange that are payable by
a federal Healthcare program.
Anti-Kickback Safe Harbors✔✔1. Referrals made as part of an employment or
professional services agreement
2. Payments made for the lease equipment or of office space
, 3. Certain payments made for the purposes of health practitioner recruitment.
Stark Law✔✔Part of OBRA, bans physicians from referring lab specimens or other
DHS to any entity with which the physician has a financial relationship.
Balance Budget Act✔✔Legislation containing major reform of Medicare and
Medicaid programs especially in the areas of home health and patient transfers. It
mandates permanent exclusion from participation in federally funded healthcare
programs of those convicted of three healthcare related crimes.
HITECH✔✔Enacted as part of ARRA, HITECH is designed to encourage healthcare
providers to adopt health information technology that establish electronic health
records in a standardized manner that protects patients private health information.
HIPAA✔✔Comprehensive legislation that ensures access to health coverage for
those who change jobs or are temporarily out of work. It also provides the
mechanism for funding the DOJ and FBI for Medicare fraud investigations.
Sherman Antitrust Act✔✔Prohibits conspiracies in restraint of trade that affects
interstate commerce. Physicians usually use this to file lawsuits against hospitals for
denial or removal of admitting privileges.
OCR✔✔A component of the Department of HHS that teaches healthcare workers
about civil rights, health information privacy, and patient safety confidentiality laws.
Retrospective Audit✔✔Audit completed after payment has been received from a
carrier. MCOs review claims that have been paid to a physician practice over a set
period of time to determine whether there has been overpayment of claims.
AMA Model Managed Care Contract Sec. 3.10(d)✔✔Provides that all payments to
physicians and physician groups/networks will be final unless adjustments are
requested in writing by the MCO within 180 days after receipt.
Medical Administrative Contracter (MAC)✔✔A private healthcare insurer that has
been awarded a geographic jurisdiction to process Medicare Part A and B medical
claims or DME claims for Medicare fee-for-services beneficiaries. They also audit
institutional provider cost reports, redetermination request (1st stage of appeals
process) and respond to provider inquiries.
Medicare Prescription Drug Improvement and Modernization Act (MMS) of
2003✔✔Directed CMS to replace Part A Fiscal Intemediaries and Part B carriers
with MACs.
Fraudulent Billing✔✔Willful and is undertaken with the intent to receive payment for
services not legitimately rendered.
Erroneous Billing✔✔Billing error that occurs unknowingly and without malice.
answers
Deficit Reduction Act of 2005✔✔Requires that organizations receiving more than $5
million in Medicaid funds must provide education on the False Claims Act.
Corporate Integrity Agreement (CIA)✔✔A compliance program imposed by the
government, which involves substantial government oversight and outside expert
involvement in the organization's compliance activities and is generally required as a
condition of settling a fraud and abuse investigation. Negotiated primarily between
the OIG and the health care entity.
Seven Elements of a Compliance Program✔✔1. Standards of Conduct
2. Oversight & Resources
3. Education & Training
4. Auditing and Monitoring
5. Consistent and appropriate discipline
6. Reporting Processes
7. Response and Prevention of Problems
LEIE (List of Excluded Individuals)✔✔A list of individuals and organizations that are
excluded from participating/billing the federal healthcare program (i.e. Medicare).
This list is updated monthly and is the responsibility of the organization to check their
list of physicians, employees, etc. against this to prevent a violation of the False
Claims Act.
Medicare Cost Report✔✔A report that contains provider information such as facility
characteristics, utilization data, cost and charges by the cost center. If administrator's
or business associate pay appears on this that is excluded from the LEIE, it may be
liable as a FCA.
5 to 50 Years✔✔Mandatory Exclusion (felony) length
Up to 5 Years✔✔Permissive exclusion (misdemeanor) length
State Medicaid Exclusion List✔✔State Version of LEIE, also monitored monthly
False Claims Act✔✔Prohibits anyone from knowingly submitting or causing to be
submitted a false or fraudulent claim to the government.
Anti-Kickback Law✔✔Prohibits the solicitation, receiving, offering, or paying of any
remuneration directly or indirectly in cash or in kind in exchange that are payable by
a federal Healthcare program.
Anti-Kickback Safe Harbors✔✔1. Referrals made as part of an employment or
professional services agreement
2. Payments made for the lease equipment or of office space
, 3. Certain payments made for the purposes of health practitioner recruitment.
Stark Law✔✔Part of OBRA, bans physicians from referring lab specimens or other
DHS to any entity with which the physician has a financial relationship.
Balance Budget Act✔✔Legislation containing major reform of Medicare and
Medicaid programs especially in the areas of home health and patient transfers. It
mandates permanent exclusion from participation in federally funded healthcare
programs of those convicted of three healthcare related crimes.
HITECH✔✔Enacted as part of ARRA, HITECH is designed to encourage healthcare
providers to adopt health information technology that establish electronic health
records in a standardized manner that protects patients private health information.
HIPAA✔✔Comprehensive legislation that ensures access to health coverage for
those who change jobs or are temporarily out of work. It also provides the
mechanism for funding the DOJ and FBI for Medicare fraud investigations.
Sherman Antitrust Act✔✔Prohibits conspiracies in restraint of trade that affects
interstate commerce. Physicians usually use this to file lawsuits against hospitals for
denial or removal of admitting privileges.
OCR✔✔A component of the Department of HHS that teaches healthcare workers
about civil rights, health information privacy, and patient safety confidentiality laws.
Retrospective Audit✔✔Audit completed after payment has been received from a
carrier. MCOs review claims that have been paid to a physician practice over a set
period of time to determine whether there has been overpayment of claims.
AMA Model Managed Care Contract Sec. 3.10(d)✔✔Provides that all payments to
physicians and physician groups/networks will be final unless adjustments are
requested in writing by the MCO within 180 days after receipt.
Medical Administrative Contracter (MAC)✔✔A private healthcare insurer that has
been awarded a geographic jurisdiction to process Medicare Part A and B medical
claims or DME claims for Medicare fee-for-services beneficiaries. They also audit
institutional provider cost reports, redetermination request (1st stage of appeals
process) and respond to provider inquiries.
Medicare Prescription Drug Improvement and Modernization Act (MMS) of
2003✔✔Directed CMS to replace Part A Fiscal Intemediaries and Part B carriers
with MACs.
Fraudulent Billing✔✔Willful and is undertaken with the intent to receive payment for
services not legitimately rendered.
Erroneous Billing✔✔Billing error that occurs unknowingly and without malice.
