COMPLIANCE 101 STUDY GUIDE
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
Compliance Program - ANSWER following rules and regulations
Integrity Program - ANSWER values and doing the right thing
Current Compliance activities in many organization - ANSWER o Equal Employment Opportunity
Commission (EEOC)
o Employee Retirement Income Security Act (ERISA)
o Wage and Hour Rule
o Occupational Safety and health Administration (OSHA)
o Nuclear Regulatory Commission
o Joint Commission on Accreditation of Healthcare Organization (JCAHO)
o Research compliance
What is a Compliance Program? - ANSWER o Prevention, Detection, Collaboration, and Enforcement
o System of policies and procedures developed to assure compliance with and conformity to all
applicable federal and state laws governing organization
o Ongoing process, part of fabric of organization, commitment to ethical way of conducting business
Who needs compliance? Why? - ANSWER o Physicians practices
o Medicare
o Ambulance Services
o 3rd Party Billing
o Pharmaceutical Manufacturing
o Hospitals
o Laboratories
o DME
,o Home Health
HHS Office of Inspector General (OIG) in conjunction with Justice Department is responsible for enforcing
the rules and regulations under
-Medicare/Medicaid laws
outlined as part of the
- Social Security Act and administered by - ANSWER CMS
Government estimates on fraud - ANSWER 10% of total US health care expenditures, about $100 billion
annually
Justice Department - ANSWER Violent Crime - 1st Priority
Health care fraud - 2nd Priority
Benefits of Compliance Program - ANSWER - Safeguards organization legal responsibility to abide by
applicable laws and regulations
- Demonstrate to employee and community the organization's commitment to good corporate conduct
- Identify and prevent criminal and unethical conduct
- Improve the quality of patient care
-Create a centralized source of information on heath care regulations
- Develop a methodology that encourages employees to report potential problems
- Develop procedures that allow the prompt, thorough investigation of alleged misconduct
- Initiate immediate and appropriate corrective action
- Reduce the organization remedies, such as program exclusion
Per OIG "Current CMS reimbursement principles provide that certain of the costs associated with the
creation of a voluntarily established compliance program may be allowable on certain types of hospital's
cost report. The allowable costs, of course must at a minimum, be reasonable and related to patient
care." However, government imposed compliance program, or corporate integrity agreement, are not
allowed
Why Compliance Programs are Essential - ANSWER Payback to fiscal intermediaries or carriers may result
in audited services
, Probation and court imposed programs
Government designed programs
Exclusion from government program
Reduced threat of qui tam (whistle-blower) lawsuit
OIG Top 10 Reason to Implement a Compliance Program - ANSWER 1. Adopting a compliance program
concretely demonstrates to the community at large that a provider has a strong commitment to honesty
and responsible corporate citizenship.
2. Compliance programs reinforces employee' innate sense of right and wrong.
3. An effective compliance program helps a provider fulfill its legal duty to government and private
payors.
4. Compliance programs are cost effective.
5. A compliance program provides a more accurate view of employee and contractor behavior relating to
fraud and abuse.
6. The quality of care provided to patients is enhanced by an effective compliance program.
7. A compliance program provides procedures to promptly correct misconduct.
8. An effective compliance program may mitigate any sanction imposed by the government.
9. Voluntarily implementing a compliance program is preferable to waiting for the OIG to impose a
Corporate Integrity Agreement (CIA).
10. Effective corporate compliance programs may protect corporate directors from personal liability.
Corporate Integrity Agreement(CIA) - ANSWER If provider does not have one in place, the OIG will
develop on that is enforceable through corporate integrity agreement. CIA has detailed policy, training,
audit, and reporting requirement that are typically in force for 5 years and involved substantial oversight.
HIPAA act of 1996 - ANSWER makes it a criminal offense to submit claims based on incorrect codes or
medically unnecessary services and the government has the power to exclude the organization from
Medicare, Medicaid, and a long list of other government.
Balance Budget Act of 1997 - ANSWER has three strike rule - 3 strikes and you're out clause, requiring
permanent expulsion for healthcare organization found guilty of fraud a third time.
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
Compliance Program - ANSWER following rules and regulations
Integrity Program - ANSWER values and doing the right thing
Current Compliance activities in many organization - ANSWER o Equal Employment Opportunity
Commission (EEOC)
o Employee Retirement Income Security Act (ERISA)
o Wage and Hour Rule
o Occupational Safety and health Administration (OSHA)
o Nuclear Regulatory Commission
o Joint Commission on Accreditation of Healthcare Organization (JCAHO)
o Research compliance
What is a Compliance Program? - ANSWER o Prevention, Detection, Collaboration, and Enforcement
o System of policies and procedures developed to assure compliance with and conformity to all
applicable federal and state laws governing organization
o Ongoing process, part of fabric of organization, commitment to ethical way of conducting business
Who needs compliance? Why? - ANSWER o Physicians practices
o Medicare
o Ambulance Services
o 3rd Party Billing
o Pharmaceutical Manufacturing
o Hospitals
o Laboratories
o DME
,o Home Health
HHS Office of Inspector General (OIG) in conjunction with Justice Department is responsible for enforcing
the rules and regulations under
-Medicare/Medicaid laws
outlined as part of the
- Social Security Act and administered by - ANSWER CMS
Government estimates on fraud - ANSWER 10% of total US health care expenditures, about $100 billion
annually
Justice Department - ANSWER Violent Crime - 1st Priority
Health care fraud - 2nd Priority
Benefits of Compliance Program - ANSWER - Safeguards organization legal responsibility to abide by
applicable laws and regulations
- Demonstrate to employee and community the organization's commitment to good corporate conduct
- Identify and prevent criminal and unethical conduct
- Improve the quality of patient care
-Create a centralized source of information on heath care regulations
- Develop a methodology that encourages employees to report potential problems
- Develop procedures that allow the prompt, thorough investigation of alleged misconduct
- Initiate immediate and appropriate corrective action
- Reduce the organization remedies, such as program exclusion
Per OIG "Current CMS reimbursement principles provide that certain of the costs associated with the
creation of a voluntarily established compliance program may be allowable on certain types of hospital's
cost report. The allowable costs, of course must at a minimum, be reasonable and related to patient
care." However, government imposed compliance program, or corporate integrity agreement, are not
allowed
Why Compliance Programs are Essential - ANSWER Payback to fiscal intermediaries or carriers may result
in audited services
, Probation and court imposed programs
Government designed programs
Exclusion from government program
Reduced threat of qui tam (whistle-blower) lawsuit
OIG Top 10 Reason to Implement a Compliance Program - ANSWER 1. Adopting a compliance program
concretely demonstrates to the community at large that a provider has a strong commitment to honesty
and responsible corporate citizenship.
2. Compliance programs reinforces employee' innate sense of right and wrong.
3. An effective compliance program helps a provider fulfill its legal duty to government and private
payors.
4. Compliance programs are cost effective.
5. A compliance program provides a more accurate view of employee and contractor behavior relating to
fraud and abuse.
6. The quality of care provided to patients is enhanced by an effective compliance program.
7. A compliance program provides procedures to promptly correct misconduct.
8. An effective compliance program may mitigate any sanction imposed by the government.
9. Voluntarily implementing a compliance program is preferable to waiting for the OIG to impose a
Corporate Integrity Agreement (CIA).
10. Effective corporate compliance programs may protect corporate directors from personal liability.
Corporate Integrity Agreement(CIA) - ANSWER If provider does not have one in place, the OIG will
develop on that is enforceable through corporate integrity agreement. CIA has detailed policy, training,
audit, and reporting requirement that are typically in force for 5 years and involved substantial oversight.
HIPAA act of 1996 - ANSWER makes it a criminal offense to submit claims based on incorrect codes or
medically unnecessary services and the government has the power to exclude the organization from
Medicare, Medicaid, and a long list of other government.
Balance Budget Act of 1997 - ANSWER has three strike rule - 3 strikes and you're out clause, requiring
permanent expulsion for healthcare organization found guilty of fraud a third time.
