Download CHC Practice Questions (Scenarios) and Verified Answers: Healthcare Compliance and more Exams Public Health in PDF only on Docsity!
CHC PRACTICE QUESTIONS (SCENARIOS) AND VERIFIED ANSWERS
"For monitoring activities, OIG uses the term regularly to describe the frequency of review. Which factors should an organization consider when establishing a frequency schedule for monitoring: a. Timing of staff job performance evaluations, how often compliance training is provided, whenever computer upgrades occur, and how many new employees were hired in the target department. b. Size of organization, frequency of the activity being monitored, past incidences of misconduct, and current/future investigations. c. Whether organization used internal or external counsel, timing of the annual financial audit,
and number of hotline calls received. - CORRECT ANSWER b. Size of organization, frequency of
the activity being monitored, past incidences of misconduct, and current/future investigations. Ref. Healthcare Compliance Professional's Manual" "An employee has violated the non-retaliation policy, he has spread rumors about employee who reported him. The compliance professional's first action is to: a. Create formal hearing for the violator b. Pursue legal consequence against violator before pursuing work consequences c. Recommend disciplinary actions against the violator of the non-retaliation policy
d. Dismiss both employees from work - CORRECT ANSWER c. Recommend disciplinary actions
against the violator of the non-retaliation policy" "There is no established template for documenting compliance risks. Each organization should develop a Risk Assessment that fits its risk profile. The components that are commonly used throughout the industry are as follows EXCEPT: a. Risk Assessment b. Measuring key risk indicators c. Identifying key performance indicators
d. Training the leadership of compliance regulation program - CORRECT ANSWER d. Training
the leadership of compliance regulation program Ref. ABA CRCM (certified regulatory compliance manager)" "To be effective, compliance risk management professionals must design a framework to ensure that management understands the risks and steps to take to mitigate them. The many roles compliance professionals fill incorporate risk management aspects including: a. overseeing compliance training targeting higher risk areas
b. tracking regulatory proposals or final rules to understand new risks
c. both a and b - CORRECT ANSWER c. both a and b
Ref. ABA CRCM (certified regulatory compliance manager)" "After an investigation, it was discovered that the organization's reputation is at stake. What should a Compliance Professional do next? A. Report the findings to the board B. Contact legal counsel C. Advise the CEO and recommend next steps
D. Self-disclose to the OIG - CORRECT ANSWER B. Contact legal counsel"
"The privacy officer for a hospital has updated the Notice of Privacy Practices/NPP to reflect a material change because the previous notice did not have a description that individuals have the right to amend their PHI. The 3rd party review team identified that the NPP did not have the required information to let individuals know of their right to amend PHI. What's the BEST course of action to correct deficiency? A. Make arrangements to mail the new NPP mailed to all patients seen within the last year at the hospital B. Make arrangements to have the new NPP distributed to new patients that come to the hospital C. Post a copy of the new NPP on the hospital's internal intranet so that all employees can see the updated version of the notice D. Meet with legal to discuss how to best self-disclose to OCR that the hospital was in violation of
the NPP requirements and has since corrected the deficiency - CORRECT ANSWER B. Make
arrangements to have the new NPP distributed to new patients that come to the hospital The NPP must describe the following individual rights: https://www.law.cornell.edu/cfr/text/45/164.
- The right to request restrictions on uses or disclosures of PHI for treatment, payment or healthcare operations; for use in a facility directory (if applicable); or to family members and others involved in the patient's care; however, the provider is not required to agree to the restriction except in the case of a disclosure to a health insurer if the individual has paid for the care as required by §164.522(a)(1)(vi). This is a change necessitated by the Omnibus Rule.
- The right to receive confidential communications by alternative means or at alternative locations per §164.522(b).
- The right to inspect and copy PHI per § 164.524. The provider may want to include a statement that the provider may charge a reasonable cost-based fee for copies.
- The right to amend PHI per § 164.526.
Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorization of the student or student's parent. OR
No. The HIPAA Privacy Rule mandates parental consent in this case. - CORRECT ANSWER Yes!
Ref. https://www.hhs.gov/hipaa/for-professionals/faq/ferpa-and-hipaa/index.html" "You are the new compliance officer for a hospital and see that it is currently under an OIG CIA. What would be the first course of action in your new position? a. Review the current OIG Work Plan and update the audit schedule for the hospital. b. Review the Code of Conduct and Policies and Procedures and update them as appropriate. c. Meet with the Compliance Board and discuss your vision of how compliance will be run in the future.
d. Review the audit schedule and pick up where the previous compliance officer left off. -
CORRECT ANSWER b. Review the Code of Conduct and Policies and Procedures and update
them as appropriate." "In development of the annual work plan, physician contract compliance was prioritized as a high- risk area. When the compliance professional followed up with management, it appeared that the monitoring identified for this area was never put into place. Which of the following should be the compliance professional's FIRST step? a. Develop a corrective action plan b. Identify a statistically valid sample c. Conduct a probe sample
d. Notify legal counsel - CORRECT ANSWER c. Conduct a probe sample"
"An individual's understanding of the compliance aspects of their job can be BEST enhanced by including compliance in a. annual evaluations b. exit interviews c. HR benefit material
d. audit committee meetings - CORRECT ANSWER a. annual evaluations"
"Which is the underlying principal of the Equal Employment Opportunity law? a. This law requires all persons to be entitled to equal employment opportunity regardless of race, religion, or national origin.
b. This law requires all minorities to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. c. This law requires all persons to be entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. d. This law requires all persons be entitled to equal employment opportunity regardless of sex,
age, or disability. - CORRECT ANSWER c. This law requires all persons to be entitled to equal
employment opportunity regardless of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. It is important for a compliance officer to understand that all persons are legally entitled to equal employment regardless of their race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. Failure to abide by the Equal Employment Opportunity law can bring forth lawsuits based on unlawful discrimination. Note: practice question from AAPC CPCO Ch8" "Most expenses related to developing and implementing a compliance program are considered the cost of doing business and are tax deductible for the organization. Which of the following is NOT tax deductible? a. When the expense costs are more than the national average b. When the expenses are a result of the imposition of a penalty c. The annual maintenance of the program
d. The salary of the compliance officer - CORRECT ANSWER b. When the expenses are a result
of the imposition of a penalty. CIA is a penalty imposed upon the organization and, as with any other governmental penalty; the expense of the development, implementation, and maintenance of this program cannot be included as a deductible expense to the organization. Note: practice question from AAPC CPCO Ch2" "Related to Corporate Integrity Agreements with the government, what is an IRO and what are the details of how it works? Choose 2 answers. a. Independent Reorganization Operation. b. They do the auditing required by a CIA. c. The OIG hires them.
d. They need to be fair and unbiased and can't have a financial relationship with the hospital. -
CORRECT ANSWER b. They do the auditing required by a CIA.
"A compliance professional is reviewing the policies and procedures for exclusion verifications. The policy does not state frequency of exclusion verifications. How frequent should exclusion verifications be performed? a. Annually b. Bi-annually c. Monthly
d. Semi-annually - CORRECT ANSWER c. monthly (as recommended by OIG to avoid risk)"
"A hotline caller states the coding department was instructed to code based on LCD requirements regardless of medical record information. Which of the following should be the compliance professional's FIRST action? a. direct the coding supervisor to follow the applicable policy b. incorporate the coding issue into next year's risk assessment c. design a review to find facts and circumstances related to the compliant
d. engage outside counsel to protect the underlying facts from discovery - CORRECT ANSWER
c. design a review to find facts and circumstances related to the compliant" "Your organization needs to conduct an audit of its billing practices. Which of the following sampling issues is NOT correct? a. The time frame of the samples should reflect the scope of the audit b. A small sample should not be used because it is not statistically meaningful c. A large sample is not necessary because there is little variability in the sample population d. The validity of a sampling plan is contingent on having a reasonable sound compliance plan in
place - CORRECT ANSWER b. A small sample should not be used because it is not statistically
meaningful" "A compliance professional identified an issue with medical necessity. The compliance professional should collaborate with the: a. case manager b. billing clerk c. documentation specialist
d. patient account representative - CORRECT ANSWER a. case manager"
"Your organization recently completed a contemporaneous audit of laboratory billing practices and found that copays have been written off. Which of the following should be your next step? a. Talk to the billing department to see why this is happening b. Conduct a retrospective audit to see if this occurred in the past c. Self-disclose this issue to limit the chance of a qui-tam suit
d. Fire the employee so the problem goes away - CORRECT ANSWER a. Talk to the billing
department to see why this is happening" "You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? A. Call the local law enforcement B. Perform another review C. Contact your compliance department D. Discuss your concerns with your supervisor
E. Follow your pharmacies procedures - CORRECT ANSWER E. Follow your pharmacies
procedures Since this is a minor discrepancy in the inventory you are not required to notify the DEA. You should follow your pharmacies procedures to determine the next steps." "When a provider's Self-Disclosure is made in good faith and fully cooperates with the OIG's review and resolution, incentives for disclosure may include: a. reduced damages by 10% b. lower settlement and no CIA c. no civil monetary penalties, 100% forgiveness
d. none of the above - CORRECT ANSWER b. lower settlement and no CIA
Payment of a lower settlement (or lower multiplier in single damages) and no CIA if the organization has cooperated fully. Ref: OIG's Provider SDP - section I.B: Benefits of Disclosure. https://oig.hhs.gov/compliance/self- disclosure-info/files/Provider-Self-Disclosure-Protocol.pdf" "The claims department needs to determine the initial baseline view of a particular billing practice to represent the beginning of a review process. What type of audit should be conducted? a. A probe audit b. Retrospective Audit c. A contemporaneous review
d. Retroactive audit - CORRECT ANSWER c. A contemporaneous review"
"A compliance professional is conducting a policy review. Which of the following procedures MUST be included in the policy for statistically valid sampling and extrapolation? a. financial error rate exceeds 5% with a refund to occur within 60 days b. financial error rate exceeds 5% with a refund to occur within 90 days
"A preliminary investigation identified payments to physicians for medical directorship without written contracts. Which of the following should be the compliance professional's NEXT step? a. determine if Medicare payments were received b. initiate a voluntary disclosure c. provide education to contracting office
d. refund payments to the contractors - CORRECT ANSWER a. determine if Medicare
payments were received" "In an investigation, the MOST important responsibility of the compliance professional is to a. personally conduct all investigations b. assure independence in investigations c. set the scope and sample size related to investigations
d. remain within the budget for investigations - CORRECT ANSWER c. set the scope and
sample size related to investigations" "An employee reports a potential problem with the attending physician's presence for surgery. Which of the following is the compliance professional's BEST action? a. investigate the issue b. approach the surgeon c. notify the OIG
d. request copies of the records - CORRECT ANSWER a. investigate the issue"
"When can patients instruct their provider not to share information about their treatment with their health plan? a. Never, patients must disclose all information to their health plan. b. Only if the patient tells the secretary when scheduling an appointment that their information should not be given to their health plan. c. If, when scheduling an appointment, the patient indicates that they are paying cash for the visit and do not want their information to be given to the health plan.
d. Never, because the health plan has a contract with the provider. - CORRECT ANSWER c. If,
when scheduling an appointment, the patient indicates that they are paying cash for the visit and do not want their information to be given to the health plan. Remember: Patients also have the right to request restrictions on the use and disclosure of their PHI to carry out treatment, payment, and healthcare operations. These requests do not have to be agreed to by the covered entity, except when a patient pays by cash, which allows the patient to instruct the provider not to share information about their treatment with the health plan. Note: practice question from AAPC CPCO Ch5"
"In the course of an audit, you find that a provider and a secretary have been repeatedly violating the privacy of an individual. The provider was given a verbal warning and the secretary was written up and suspended for 3 days. What would your first course of action be? a. Do nothing, as each division/clinic manager has powers to do as they like. b. Get HR involved and recommend that discipline should be fair, equitable, and consistent. c. Immediately report the incident to OCR.
d. Get local and federal labor department involved for unfair discipline. - CORRECT ANSWER b.
Get HR involved and recommend that discipline should be fair, equitable, and consistent." "A billing manager is reviewing the monthly reimbursement report for the department. The manager notices that there is an increase of 50% over the expected amount of incoming payments from Federal health care programs for treatment of patients. The manager believes action is needed. The manager's NEXT step is to:
- Stop all outgoing claims to Federal health care programs
- Extrapolate the last 6 months of reimbursement totals to identify the overpayment due to health care programs
- Contact legal for next steps or further direction to include advice on how to proceed with the self disclosure protocol
- Analyze the details related to the increase in payments to identify possible sources or causes
for increase in reimbursement - CORRECT ANSWER 4. Analyze the details related to the
increase in payments to identify possible sources or causes for increase in reimbursement" "Sue works for ABC Family Physicians. The providers at this office ask her to research the department that helps protect patients from unfair treatment or discrimination. What department or agency would that be? a. Equality in Employment Agency b. Office for Civil Rights c. Department of Justice
d. Office of Inspector General - CORRECT ANSWER b. Office for Civil Rights (OCR)
DOL oversees employment discrimination DOJ enforces federal criminal law and implements criminal law policies OIG combats FWA in Medicare, Medicaid and HHS Programs Note: practice question from AAPC CPCO Ch1" "Why should compliance officers set disciplinary policies for non-compliance? a. Employees need rules to follow. b. Employees should know the consequences for non-compliance of set policies.
D. Random Sampling - CORRECT ANSWER A. Statistical Sampling"
"Compliance audits indicate a five-year trend of decreasing numbers of compliance issues. The compliance professional is considering whether the auditing program needs to be continued because there is also a robust monitoring program in place. Which of the following is the MOST compelling reason to continue the auditing program: A. Audits are part of an effective compliance program. B. Necessary compliance training cannot be identified without auditing. C. It helps the Board of Directors understand the compliance program.
D. Staff cannot recognize compliance issues without auditing. - CORRECT ANSWER A. Audits
are part of an effective compliance program" "In an organization, a compliance program must not have only a plan. It must be: A. Audited and Monitored on an ongoing basis, to capture any vulnerability in the program. B. Testing the compliance program on a regular basis, provides assurance. C. Senior management and Board of Directors are aware of the risk areas that require priority attention. D. Auditing and Monitoring, identify new risk in an area, so action can be taken before it gets pervasive.
E. All of the above - CORRECT ANSWER E. All of the above"
"An employee has filed a complaint via the hotline that she received disciplinary action for a violation that her coworker's members did not get disciplined for. Which of the following would be the BEST step for the compliance professional to take? a. Contact Legal Counsel b. Contact Human Resources Director to assist with the investigation. c. Speak with the department to see if the employee is retaliating. d. Independently verify the facts, by looking at the disciplinary actions for the employee and the
other staff members. - CORRECT ANSWER b. Contact Human Resources Director to assist with
the investigation. Remember, compliance enforces discipline through standards/P&Ps, but HR and management ultimately impose disciplinary actions." "The billing manager informed you she discovered a billing error by the laboratory in the course of doing NCCI edits. The error was XYZ and the identified overpayments will be refunded. The lab director established a new process to prevent this error from recurring. As the compliance professional, what should you do to prevent this from recurring? a. Conduct a statistically significant audit of all laboratory billing
b. Establish a monitoring plan for the lab billing process c. Hire an external auditor to determine if these bills were erroneous
d. Ask the lab director to conduct a probe audit of lab billing and coding processes - CORRECT
ANSWER b. Establish a monitoring plan for the lab billing process.
Note: National Correct Coding Initiative (NCCI) edits are code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual preventing. https://med.noridianmedicare.com/web/jeb/topics/claim-submission/ncci" "Which of the following are MOST relevant in evaluating the effectiveness of a compliance training program?
- percent of target audience that has attended
- whether the training is computer-based or classroom-based
- whether training adequately addresses areas of concern
- improvement shown in pre- and post-training quizzes A. 1, 2, 3 only B. 1, 2, 4 only C. 1, 3, 4 only
D. 2, 3, 4 only - CORRECT ANSWER C. 1, 3, 4 only"
"Fraud, waste, and abuse are all areas that must be controlled when providing services to beneficiaries. Which statement is TRUE regarding fraudulent billing? a. A series of errors is considered fraudulent billing. b. Fraudulent billing is only an issue if the erroneous billing is identified and not resolved. c. Fraudulent billing only occurs when refunds are not issued in a timely manner.
d. Fraudulent billing is a willful act with intent to receive payment for services not rendered. -
CORRECT ANSWER d. Fraudulent billing is a willful act with intent to receive payment for
services not rendered. Note: practice question from AAPC CPCO Ch2" "The False Claims Act contains a whistleblower-protection provision for persons reporting fraud and abuse. What does this mean? a. Persons reporting fraud or abuse may be subject to the same penalties as the persons committing the fraud or abuse. b. Persons reporting fraud or abuse can be discharged or demoted. c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.
a. To the entire 2014 Fiscal Year b. To their two other Hospitals and the entire 2014 Fiscal Year c. Both of the above
d. None of the above - CORRECT ANSWER a. To the entire 2014 Fiscal Year"
"Which government department is comprised of thousands of employees who enforce the nation's federal criminal laws and help develop and implement criminal law policies? a. Office of Inspector General b. Centers for Medicare & Medicaid Services c. Healthcare Lawyers Association
d. Department of Justice - CORRECT ANSWER d. Department of Justice
OIG combats FWA in Medicare, Medicaid and HHS Programs; CMS administers the nation's major healthcare programs including Medicare, Medicaid, and CHIP to eliminate FWA; HLA is an edu org (not a gov department). Note: practice question from AAPC CPCO Ch1" "The most updated DOJ ECCP (Evaluation of Corporate Compliance Programs) provides additional guidance to prosecutors. Which of the following are included in the ECCP revisions (Sep 2024)? a. DOJ expects company's compliance program to include safeguards to better monitor and manage potential compliance risk regarding new technologies (e.g., A.I.) b. DOJ expects company's to integrate these new technology related risks into broader enterprise risk management (ERM) strategies c. the guidance expands on post-acquisition compliance integration and use of data for compliance purposes
d. all of the above - CORRECT ANSWER d. all of the above"
"You reviewed 30 inpatient claims and the error rate was higher than the threshold that had been set, indicating possibility of a problem. To assess the seriousness of the problem, you would pull what type of sample: a. Probe b. Discovery c. Full statistical
d. Situational - CORRECT ANSWER b. Discovery
Remember: Probe (30 units) - Discovery (50 units) - Full Statistical (100% of universe)" "An emergency medical condition is defined as having symptoms (including severe pain and psychiatric disturbances) such that the absence of immediate medical attention could result in:
a. Being brought to the hospital by ambulance. b. Loss of wages for not being able to work. c. Serious comorbidities developing in the future. d. Serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part.
- CORRECT ANSWER d. Serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part. An emergency medical condition is defined as having symptoms (including severe pain and psychiatric disturbances) such that the absence of immediate medical attention could result in: (1) placing the health of the individual (or unborn child) in serious jeopardy; (2) serious impairment of bodily functions, and/or serious dysfunction of any bodily organ or part. With a pregnant woman having contractions, an emergency medical condition also means there is not enough time to safely transfer the woman prior to delivery, or the transfer would pose a threat to her or her unborn child. Note: practice question from AAPC CPCO Ch6" "A compliance professional has received a complaint through the compliance hotline. The employee making the complaint alleged that she received discipline that was unfair because she had a co-worker who committed the same violation and received a lesser punishment. What should the compliance professional do FIRST? a. Review performance evaluation to see if there were any performance issues for the employee who made the complaint b. Review policy concerning disciplinary action c. Review the disciplinary actions taken against the two employees to see if the allegation is true.
d. Contact the employee to obtain or gather information about her allegation - CORRECT
ANSWER d. Contact the employee to obtain or gather information about her allegation"
"A provider receives a request from the Social Security Administration for PHI relating to a person's application for benefits. Which of the following is the correct method of release? A. Since it is to a federal agency, an authorization from the patient is not needed, so PHI can be released. B. The provider should review the PHI and make a decision on the minimum necessary and release. C. The provider should notify the patient and obtain a signed authorization prior to release.
D. Release the information because the patient signed a consent for treatment. - CORRECT
ANSWER C. The provider should notify the patient and obtain a signed authorization prior to
release"
B. 2 and 4 only C. 3 only
D. All listed - CORRECT ANSWER A. 1 and 3 only"
"You used the OIG sampling program RAT-STATS to select a statistical sample. Some of the files you pulled are messy and would take a long time to review. You saw some other files that looked well organized. As long as you replace one of the "messy" files one-to-one with a "neat" one that you find, to keep the sample size the same, how many of the files can you replace? a. 10 files, regardless of sample size b. 10% of the sample size c. Unlimited number of files
d. None of the above - CORRECT ANSWER d. None of the above"
"A Whistleblower recently identified a number of fraudulent Medicare claims. Her husband is asking about a potential reward, which statement is true. a. She must inform the organization about the claims before notifying the government b. If DOJ takes the case, she could receive at least 15% of government total award c. She must at least try to resolve the claims issue
d. None of the above - CORRECT ANSWER b. she could receive at least 15% of total reward
Explanation: The government has no requirements about a whistleblower informing or resolving an issue first. The government wants to encourage an environment of trust where problems are brought forward. Remember: Whistleblowers can be eligible to receive 15-25% (DOJ assumes case) or 25-30% (DOJ declines case)" "Any laboratory performing testing on specimens derived from a human being for purposes of providing diagnosis, prevention, treatment, or assessment of health, regardless of whether they participate in Medicare, must: a. Participate in a quality assurance program b. Maintain adequate hours of operation for the underserved community c. Enroll in the CLIA program
d. Have a certificate of compliance - CORRECT ANSWER c. Enroll in the CLIA program
Note: practice question from AAPC CPCO Ch6" "Primary safety concerns in the medical setting include bloodborne pathogens, radiation, bio- hazardous waste, and ________. a. closed spaces b. chemicals c. patient care equipment
d. non-patient care equipment - CORRECT ANSWER b. chemicals
Key issues in a medical setting are bloodborne pathogens, radiation, chemicals, and bio- hazardous waste. Note: practice question from AAPC CPCO Ch7" "If I'm only doing blood draws, do I need a CLIA number? a. No, a CLIA number is not required if the facility only collects specimens and performs no testing. b. No, a CLIA number is not required if the facility only collects specimens and performs minor testing. c. Yes, a CLIA number is required if the facility only collects specimens, even if they perform no testing.
d. Yes, a Medicare-participating provider that only collects specimens requires a CLIA number. -
CORRECT ANSWER a. No, a CLIA number is not required if the facility only collects specimens
and performs no testing. Note: practice question from AAPC CPCO Ch6" "A privacy official is asked to approve a transfer form that would have the patient's SS# on the top of the page when a patient is transferred from the privacy officer's facility to another facility. The nursing leadership at the facility is insisting that they "have to have" the patient's SS# when making transfer arrangements from one facility to another. The BEST course of action for the privacy officer to take is: A. Ask the nursing leadership to update the policy on transfers to include that social security numbers must be included on transfer paperwork. B. Have the appropriate forms updated/revised/edited so that they can now accommodate the social security numbers. C. Confirm with nursing any regulations or other requirements that state social security numbers must be included on transfer forms
D. Contact the legal department. - CORRECT ANSWER C. Confirm with nursing any regulations
or other requirements that state social security numbers must be included on transfer forms"
