Compliance 101 Exam/ 107 Q&A/ A+ Score
Solution
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.
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,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
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, 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.
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
Page 3 of 19
Solution
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.
Page 1 of 19
,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
Page 2 of 19
, 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.
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
Page 3 of 19
