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The |! Joint |! Commission |! (JC) |! requires |! the |! Factors |! that |! Affect |! Learning |! must |! be |! assessed |! for |! a |! hospital |! or |! hospital |! owned |! physician |! practice |! as |! well |! as |! other |! health |! care |! facilities. |! When |! assessing |! this |! element |! what |! does |! this |! include? A. |! The |! patient's |! ability |! to |! read, |! method |! of |! learning |! and |! understanding. B. |! Any |! language |! or |! physical |! disabilities. C. |! Cultural |! beliefs. D. |! All |! the |! above |! - |! Correct |! answer |! ✔D. |! All |! the |! above Report |! copies |! and |! printouts, |! films, |! scans, |! and |! other |! radio |! logic |! service |! image |! records |! must |! be |! retained |! for |! how |! long |! according |! to |! Federal |! Regulations? A. |! 10 |! years B. |! 7 |! years C. |! 5 |! years
D. |! 3 |! years |! - |! Correct |! answer |! ✔C. |! 5 |! years At |! which |! point |! should |! a |! provider |! repay |! over |! payments |! reported |! by |! self- disclosure |! to |! the |! office |! of |! Inspector |! General? A. |! Make |! the |! payment |! to |! your |! carrier |! immediately. B. |! Make |! the |! payment |! at |! the |! conclusion |! of |! the |! OIG |! injury. C. |! Make |! the |! payment |! to |! the |! carrier |! prior |! to |! the |! self |! disclosure. D. |! Make |! the |! payment |! to |! the |! OIG |! with |! a |! self |! disclosure |! report. |! - |! Correct |! answer |! ✔B. |! Make |! the |! payment |! at |! the |! conclusion |! of |! the |! OIG |! injury Which |! of |! the |! following |! may |! be |! considered |! essential |! element |! (s) |! of |! an |! operative |! report |! and |! will |! allow |! for |! accurate |! coding? A. |! The |! approach B. |! The |! type |! of |! anesthesia |! required C. |! The |! location |! and |! severity |! of |! wounds |! repaired D. |! All |! of |! the |! above |! - |! Correct |! answer |! ✔D. |! All |! of |! the |! above Which |! of |! the |! following |! is |! NOT |! a |! covered |! entity |! under |! HIPPA?
A. |! Prior |! to |! performing |! a |! statutorily |! excluded |! procedure |! for |! a |! Medicare |! beneficiary. B. |! Prior |! to |! performing |! a |! procedure |! that |! may |! be |! denied |! due |! to |! medical |! necessity |! for |! a |! Medicare |! beneficiary. C. |! Prior |! to |! submitting |! a |! claim |! to |! Medicaid |! for |! a |! non- |! service. D. |! After |! performing |! a |! procedure |! and |! finding |! it |! is |! denied. |! - |! Correct |! answer |! ✔B. |! Prior |! to |! performing |! a |! procedure |! that |! may |! be |! denied |! due |! to |! medical |! necessity |! for |! a |! Medicare |! beneficiary. Under |! a |! Corporate |! Integrity |! Agreement |! (CIA), |! how |! many |! claims |! must |! be |! randomly |! selected |! to |! review |! to |! determine |! the |! financial |! error |! rate? A. |! 15 B. |! 50 C. |! 75 D. |! 100 |! - |! Correct |! answer |! ✔B. |! 50 When |! using |! LCDs |! and |! CMS |! program |! Guidance |! as |! a |! resource |! for |! an |! audit, |! what |! should |! the |! auditor |! keep |! in |! mind? A. |! QICs |! are |! bound |! by |! NCDs, |! LMRPs, |! and |! CMS |! Program |! guidance, |! but |! ALJs |! and |! MACs |! are |! not.
B. |! Local |! carriers |! and |! QICs |! are |! bound |! by |! LCDs |! and |! LMRPs C. |! Local |! carries |! follow |! LCDs, |! LMRPs, |! and |! CMS |! program |! guidance, |! but |! QICs, |! ALJs, |! and |! MACs |! are |! not |! bound |! by |! them. D. |! Local |! Carriers, |! QICs, |! ALJs, |! and |! MACs |! are |! all |! bound |! by |! NCDs |! and |! CMS |! program |! guidance. |! - |! Correct |! answer |! ✔C. |! Local |! carries |! follow |! LCDs, |! LMRPs, |! and |! CMS |! program |! guidance, |! but |! QICs, |! ALJs, |! and |! MACs |! are |! not |! bound |! by |! them. When |! reporting |! the |! claims |! review |! findings |! under |! a |! CIA |! audit, |! the |! Independent |! Review |! Organization |! (IRO) |! must |! provide: A. |! A |! detailed |! analysis |! listing |! the |! patient |! files |! reviewed |! and |! findings |! and |! previous |! audit |! disclosures |! for |! all |! services B. |! A |! detailed |! report |! with |! a |! narrative |! explanation |! of |! finding |! and |! supporting |! rationale |! approved |! by |! the |! providers |! attorney. C. |! A |! detailed |! report |! with |! an |! analysis |! and |! narrative |! explanation |! with |! findings |! and |! supporting |! rationale |! regarding |! the |! claim |! review, |! including |! the |! results |! of |! the |! discovery |! or |! full |! sample. D. |! A |! list |! of |! data |! reviewed |! and |! findings |! in |! a |! narrative |! form |! - |! Correct |! answer |! ✔C. |! A |! detailed |! report |! with |! an |! analysis |! and |! narrative |! explanation |!
A. |! Provider |! contract |! with |! XYZ |! insurance. B. |! Provider |! internal |! billing |! polices. C. |! RAC |! statement |! of |! work D. |! OIG |! work |! plan |! for |! the |! current |! year. |! - |! Correct |! answer |! ✔A. |! Provider |! contract |! with |! XYZ |! insurance. According |! to |! the |! "OIG |! Compliance |! Program |! for |! Individual |! and |! Small |! Group |! Physician |! Practices," |! There |! are |! essential |! elements |! for |! a |! compliance |! plan. |! These |! elements |! included: A. |! Mandatory |! employment |! of |! an |! internal |! auditor B. |! Conduct |! appropriate |! training |! and |! education C. |! Disciplinary |! action |! for |! employees |! who |! file |! a |! qui |! tam |! suit D. |! Develop |! an |! effective |! E/M |! Audit |! Tool |! with |! reproducible |! results. |! - |! Correct |! answer |! ✔B. |! Conduct |! appropriate |! training |! and |! education John |! presents |! today |! for |! his |! yearly |! physical |! and |! during |! the |! encounter |! he |! alerts |! his |! physician |! to |! some |! abdominal |! issues |! he |! has |! been |! having |! including |! sharp |! pains |! that |! come |! and |! go |! and |! have |! been |! increasing |! in |! severity |!
especially |! after |! eating. |! After |! examination |! the |! doctor |! orders |! an |! ultrasound |! which |! is |! performed |! in |! the |! office |! and |! medications |! and |! schedules |! a |! follow-up |! for |! two |! weeks. |! What |! is |! the |! appropriate |! modifier |! for |! this |! encounter? A. |! No |! modifier |! necessary B. |! 25 C. |! 57 D. |! 24 |! - |! Correct |! answer |! ✔B. |! 25 Which |! of |! the |! following |! accurately |! describes |! the |! financial |! impact |! for |! appending |! modifier |! 24 |! to |! an |! E/M |! service |! performed |! during |! the |! global |! period |! of |! a |! major |! surgery? A. |! The |! E/M |! service |! will |! not |! be |! paid |! when |! performed |! during |! the |! global |! period. B. |! The |! E/M |! service |! will |! be |! paid |! at |! 20% |! of |! the |! physician |! fee |! schedule C. |! The |! E/M |! service |! will |! be |! paid |! at |! 100% |! of |! the |! physician |! fee |! schedule |! minus |! the |! patients |! responsibility. D. |! The |! E/M |! service |! will |! not |! be |! paid |! and |! a |! ABN |! should |! be |! signed |! since |! the |! service |! provided |! is |! unrelated |! to |! the |! surgery. |! - |! Correct |! answer |! ✔C. |! The |! E/M |! service |! will |! be |! paid |! at |! 100% |! of |! the |! physician |! fee |! schedule |! minus |! the |! patients |! responsibility.
D. |! To |! ensure |! compliance |! with |! all |! coding |! guidelines |! - |! Correct |! answer |! ✔A. |! After |! a |! prepayment |! or |! retrospective |! audit |! has |! identified |! a |! specific |! problem Which |! of |! the |! following |! represents |! the |! most |! logical |! initial |! step |! in |! the |! audit |! process? A. |! Develop |! an |! audit |! tool |! and |! tally |! form B. |! Determine |! the |! objective(s), |! the |! type, |! and |! the |! scope |! of |! the |! audit C. |! Gather |! the |! medical |! records |! to |! be |! audited. D. |! Analyze |! the |! audit |! and |! compare |! the |! documentation |! to |! the |! procedure |! and |! diagnosis |! code(s) |! billed. |! - |! Correct |! answer |! ✔B. |! Determine |! the |! objective(s), |! the |! type, |! and |! the |! scope |! of |! the |! audit What |! are |! the |! the |! Seven |! Elements |! defined |! by |! the |! OIG? |! - |! Correct |! answer |! ✔The |! Seven |! Elements |! defined |! by |! the |! OIG |! are:
- |! Implementing |! written |! policies |! and |! procedures
- |! Designating |! a |! compliance |! officer |! and |! compliance |! committee
- |! Conducting |! effective |! training |! and |! education
- |! Developing |! effective |! lines |! of |! communication
- |! Conducting |! internal |! monitoring |! and |! auditing
- |! Enforcing |! standards |! through |! well-publicized |! disciplinary |! guidelines
- |! Responding |! promptly |! to |! detected |! problems |! and |! undertaking |! corrective |! action The |! office |! of |! Inspector |! General |! (OIG) |! - |! Correct |! answer |! ✔The |! mission |! of |! the |! Office |! of |! Inspector |! General |! is |! to |! protect |! the |! integrity |! of |! the |! Department |! of |! Health |! and |! Human |! Services |! (HHS) |! programs, |! as |! well |! as |! the |! health |! and |! welfare |! of |! the |! beneficiaries |! of |! those |! programs Fraud |! - |! Correct |! answer |! ✔Fraud |! is |! an |! intention |! deception |! made |! for |! personal |! gain. |! Fraud |! is |! a |! crime |! and |! a |! civil |! law |! violation Abuse |! - |! Correct |! answer |! ✔Abuse |! is |! an |! act |! that |! directly |! or |! indirectly |! results |! in |! unnecessary |! reimbursement |! without |! defined |! intent. A |! qui |! tam |! suit |! - |! Correct |! answer |! ✔(Whistle |! blower) |! One |! in |! which |! an |! action |! that |! will |! grant |! the |! plaintiff |! a |! portion |! of |! the |! recovered |! penalty |! and |! gives |! the |! rest |! of |! it |! to |! the |! state. How |! often |! does |! the |! Compliance |! program |! Guidance |! for |! Individual |! and |! Small |! Group |! Physician |! Practices |! recommends |! employees |! be |! trained |! on |!
The |! Civil |! False |! Claim |! Acts |! - |! Correct |! answer |! ✔Imposes |! civil |! monetary |! penalties |! of |! between |! $5,500 |! and |! $11,000 |! plus |! three |! times |! the |! value |! of |! each |! claim. |! It |! prohibits |! the |! knowing |! submission of |! a |! false |! or |! fraudulent |! claim |! for |! payment |! to the |! United |! States, |! the |! knowing |! use |! of |! a |! false |! record |! or |! statement |! to |! obtain |! payment |! on |! a false |! or |! fraudulent |! claim, |! or |! a |! conspiracy |! to defraud |! the |! United |! States |! by |! having |! a |! false |! or fraudulent |! claim |! allowed |! or |! paid The |! Criminal |! False |! Claim |! Act: |! - |! Correct |! answer |! ✔Prohibits knowingly |! and |! willfully |! making |! or causing |! to |! be |! made |! any |! false |! statement |! or representation |! of |! material |! fact |! in |! any |! claims or |! application |! for |! benefits |! under |! federally funded |! health |! plans |! as |! well |! as |! commercial carriers. |! Violations |! are |! felonies |! and |! are punishable |! by |! up |! to |! five |! years |! imprisonment and/or |! $25,000 |! in |! fines. The |! Civil |! Monetary |! Penalties |! Law: |! - |! Correct |! answer |! ✔Provides for |! the |! imposition |! of |! civil |! monetary |! penalties up |! to |! $10,000 |! per |! false |! service |! claimed, |! plus assessments |! equal |! to |! three |! times |! the |! amount
claimed, |! for |! services |! that |! the |! provider |! knows or |! should |! know |! were |! not |! provided |! as |! claimed or |! for |! claims |! the |! provider |! knows |! or |! should know |! are |! false |! or |! fraudulent. Other |! federal |! criminal |! laws: |! - |! Correct |! answer |! ✔Also |! may |! be used |! to |! prosecute |! the |! submission |! of |! false claims, |! including |! prohibitions |! on |! making false |! statements |! to |! the |! government |! and engaging |! in |! mail |! fraud. |! Felony |! convictions will |! result |! in |! exclusion |! from |! Medicare |! for |! a minimum |! of |! a |! five-year |! period. Option |! for |! Providers |! - |! Correct |! answer |! ✔Self |! Disclosure: |! Fines |! may |! be |! less |! if |! a |! practice self-disclosed |! its |! knowledge |! of |! the |! violation. |! Appeal |! Rights: |! A |! practice |! has |! the |! right |! to |! an appeal |! process, |! and |! may |! choose |! to |! request a |! hearing |! before |! an |! administration |! law judge |! (ALJ). |! The |! OIG |! and |! the |! respondent have |! the |! right |! to |! present |! evidence |! and |! make arguments |! to |! the |! ALJ, |! who |! issues |! a |! written decision. |! Additional |! Appeal: |! The |! ALJ's |! decision |! may
years Discovery |! Sample |! - |! Correct |! answer |! ✔The |! claims |! review |! procedures |! require |! a |! Discovery Sample. |! A |! Discovery |! Sample |! is |! used |! to |! determine the |! financial |! error |! rate. |! The |! Discovery |! Sample |! is |! a review |! of |! 50 |! units |! to |! be |! randomly |! selected. The |! purpose |! of |! conducting |! a |! Discovery |! Sample |! as part |! of |! the |! claims |! review |! is |! to |! determine |! the |! net financial |! error |! rate |! of |! the |! sample |! that |! is |! selected. If |! the |! net |! financial |! error |! rate |! equals |! or |! exceeds 5 |! percent, |! the |! results |! of |! the |! Discovery |! Sample are |! used |! to |! determine |! the |! Full |! Sample |! size. |! The Full |! Sample |! size |! is |! based |! on |! an |! estimate |! of |! the variability |! of |! the |! overpayment |! amount |! in |! the population |! from |! which |! the |! sample |! was |! drawn. |! The results |! of |! the |! Discovery |! Sample |! allow |! the |! reviewer to |! estimate |! how |! many |! sample |! units |! need |! to |! be reviewed |! in |! order |! to |! estimate |! the |! overpayment in |! the |! population |! within |! certain |! confidence and |! precision |! levels |! (eg, |! generally, |! a |! 90 |! percent confidence |! and |! 25 |! percent |! precision |! level
Stark |! Law |! - |! Correct |! answer |! ✔The |! Stark |! Law |! is |! primarily |! defined |! as |! a |! physician self-referral |! law, |! 42 |! USC |! 1395nn. |! Physician self-referral |! is |! defined |! by |! the |! Stark |! Laws |! as: the |! practice |! of |! a |! physician |! referring |! a |! patient to |! a |! medical |! facility |! in |! which |! he |! has |! a |! financial interest, |! be |! it |! ownership, |! investment, |! or |! a structured |! compensation |! arrangement. |! The |! Stark Law |! was |! sponsored |! by |! Congressman |! Pete |! Stark (Calif.). |! Individuals |! such |! as |! Stark |! contend |! such arrangements |! may |! encourage |! over-utilization |! of services, |! in |! turn |! driving |! up |! health |! care |! costs. |! This law |! prohibits |! a |! physician |! from |! making |! a |! referral to |! an |! entity |! with |! which |! the |! physician |! or |! his |! or |! her immediate |! family |! has |! a |! financial |! relationship |! if |! the referral |! is |! for |! the |! furnishing |! of |! designated |! health services, |! unless |! the |! financial |! relationship |! fits |! into an |! exception |! set |! forth |! in |! the |! statute |! or |! impending regulations. What |! services |! are |! not |! targeted |! by |! the |! Stark |! Law? |! - |! Correct |! answer |! ✔Services |! such |! as |! sleep |! studies, |! EKGs, |! NCVs, and |! Holter |! monitoring, |! or |! services |! personally performed |! or |! provided |! by |! the |! referring |! physician
When |! should |! a |! Self |! disclosure |! occur? |! - |! Correct |! answer |! ✔Self |! disclosure |! should |! occur |! within |! 30 days |! of |! knowing |! about |! the |! violation, |! and |! does |! not require |! any |! form |! of |! legal |! assistance. |! Payments relating |! to |! the |! disclosed |! matter |! should |! not |! be made |! until |! the |! conclusion |! of |! the |! OIG |! inquiry to |! allow |! the |! OIG |! time |! to |! verify |! the |! information disclosed How |! often |! are |! records |! requested |! from |! RAC |! auditors |! and |! how |! many? |! - |! Correct |! answer |! ✔Each |! 45 |! days, |! records |! may be |! requested |! based |! on |! the |! entity's |! size: |! less |! than |! 5 |! providers—10 |! records |! 6-24 |! providers—25 |! records |! 25-49 |! providers—40 |! records |! 50 |! or |! more |! providers—50 |! records RAC |! Audit |! Appeals |! Process |! - |! Correct |! answer |! ✔Providers |! who |! choose |! to appeal |! must |! send |! a |! rebuttal |! of |! the |! findings |! directly to |! the |! RAC |! within |! 15 |! days |! of |! receiving |! the |! RAC's
letter |! identifying |! an |! overpayment. |! Note, |! however, this |! does |! not |! stop |! the |! clock |! on |! the |! 120 |! day |! time period |! during |! which |! a |! request |! for |! redetermination (first |! level |! appeal) |! from |! the |! Medicare |! contractor must |! be |! submitted. |! Additionally, |! the |! clock |! is still |! running |! with |! regard |! to |! the |! interest |! accrued when |! money |! is |! not |! refunded |! within |! 30 |! days |! of |! the request. |! Providers |! who |! choose |! to |! send |! a |! rebuttal to |! the |! RAC |! will |! want |! to |! either |! simultaneously file |! a |! request |! for |! redetermination |! to |! the |! Medicare contractor |! or |! carefully |! track |! the |! status |! of |! the rebuttal |! and |! be |! prepared |! to |! file |! the |! request |! for redetermination |! within |! the |! 120-day |! time |! period, if |! needed. |! Medicaid |! appeals |! processes |! will |! vary from |! state |! to |! state |! as |! well |! as |! Medicare |! Advantage appeals |! will |! vary |! by |! MCO PATH |! Audits |! - |! Correct |! answer |! ✔Another |! HIPAA |! mandated |! audit |! process under |! the |! jurisdiction |! of |! the |! OIG |! operation |! is the |! Physicians |! at |! Teaching |! Hospitals |! (PATH) Audit. |! This |! audit |! process |! has |! two |! forms: |! purely government-conducted |! audits |! (PATH |! I), |! and |! a self-audit |! alternative |! (PATH |! II). |! This |! self-audit process |! implies |! through |! the |! OIG |! interpretation |! as
