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HCCA CHC ONLINE PRACTICE EXAM
2024 | 750 QUESTIONS AND
CORRECT ANSWERS (ALREADY
GRADED A+) | LATEST VERSION
The most important communication device for a compliance program is: a. Code of Conduct b. Education c. Open door policy d. All of the above -----CORRECT ANSWER----------------c. Open door policy True or False: The OIG states "an open line of communication between the CO and personnel is equally important to the successful implementation of a compliance program and the reduction of any potential fraud, waste and abuse" -----CORRECT ANSWER---------------
- True The first and best line of defense in compliance is: a. Having the hotline to report compliance violations anonymously b. Education and training c. Sufficient budget for the Compliance Department d. Written policies and procedures -----CORRECT ANSWER----------------b. Education and training What is an important first step in creating a compliance team or improving the effectiveness of an existing one? a) Making sure senior management has the time and other resources necessary to promote and carry out compliance improvements b) Give the CCO the authority to reconcile, standardize, and modify policies where appropriate. c) Place the organization's CCO on the senior management team d) None of the above -----CORRECT ANSWER----------------c) Place the organization's CCO on the senior management team.
Explanation: This comes straight form Chapter 1 of the Auditing and Monitoring book 2nd ed. Without being placed on the senior management team, the CCO is unable to effectively carry out the duties and responsibilities of the office. A healthcare provider must repay to Medicare money paid for a specific type of billed claim. What type of audit is the MOST likely one used to identify the amount of repayment? a. probe audit b. concurrent audit c. proactive audit d. full statistical audit -----CORRECT ANSWER----------------d. full statistical audit For an audit to provide a 100% confidence level of something being audited, what must occur? -----CORRECT ANSWER----------------The only way to obtain 100% confidence is to audit 100% of the population A Physician practice is having a hard time determining which claims have been paid in full, and which claim have not been paid at all. What test would be practical for the group to perform to validate the claims that have been paid or not paid. A. Statistical Sampling B. Rat-Stats C. Baseline Audit D. Random Sampling -----CORRECT ANSWER----------------A. Statistical Sampling Auditing and monitoring contribute to the effectiveness of a compliance program because of their ability to...... -----CORRECT ANSWER----------------Detect To become a Medicare biller, one must setup? -----CORRECT ANSWER---------------- Conditions of Participation (CoP) What are common health care risk areas? -----CORRECT ANSWER----------------Coding, contracts, and quality of care.
furnished. Major focus of OIG enforcement efforts and HIPAA added additional civil monetary penalty to OIG sanctions. Example: you receive 15 mins of physical therapy services...but the physician bills for 30 minutes of "advanced" physical therapy services In other words, I give you a hamburger but I bill as if I gave you a steak dinner. DRG Creep -----CORRECT ANSWER----------------Using a Diagnosis Related Group (DRG) code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient. Example: you have a cold but the physician bills for treating you with the flu. In other words, you have a sprained ankle but I bill that you have a more complex issue like a broken ankle. Steps in Risk Assessment -----CORRECT ANSWER----------------Identify Analyze/Assess Prioritize Mitigate Common functions in all organizations that should be audited (high risk areas): ----- CORRECT ANSWER----------------• AKS/Stark
- COI Documentation,
- billing, coding review
- Third Party Contract
- Compliance program effectiveness Auditing - characteristics -----CORRECT ANSWER----------------• Formalized methodology
- Objective and independent
- No real/perceived vested interest Monitoring - characteristics -----CORRECT ANSWER----------------• Day to day process
- Independence not required
- Get general sense of operational control or identify potential problem area(s)
A key factor in Monitoring -----CORRECT ANSWER----------------Scalability - workplan vs resources available to implement/complete work Monitoring & Auditing Two Step -----CORRECT ANSWER----------------First: risk assessment Second: prioritize risks - to help define the basis for what the compliance program should focus on for the next year in its plan. Retrospective Audit -----CORRECT ANSWER----------------Baseline assessment of where you are at a period of time in the past; snapshot or Laundry list of things needed to be fixed, need to know a milestone to go back to in time. Concurrent Audit -----CORRECT ANSWER----------------Real time - Ongoing review/inspection of records, policies and procedures. More difficult to execute but best way to change behavior. Identify and address problems as they arise - Example: Auditing claims before claims are billed Monitoring - Where is a good place to start? -----CORRECT ANSWER---------------- Interviewing employees, ask about their process, if policies & procedures are followed, are whether methods are sound Who is responsible for Auditing & Monitoring Compliance Risks? a. internal auditor(s) b. compliance department c. combination of the two -----CORRECT ANSWER----------------c. combination of the two. To avoid duplication or overlap, consider if there are other departments in your organization doing auditing. Various Ways to Monitor, provide examples: -----CORRECT ANSWER----------------• On site visit
Statistical Valid Sample - characterized by -----CORRECT ANSWER----------------Sample must be selected at random, no bias or distortions that can make it non-representative Can be extrapolated to make assumption about universe Precision and confidence indicate an acceptable level of sampling error Non-Statistical Sample - characterized by -----CORRECT ANSWER----------------Can't be extrapolated Can't assure sample was selected at random Compliance Reporting (complaints) -----CORRECT ANSWER----------------• Compliance Hotline or Helpline should be in place to track activity and actions taken.
- Complaints received should be handled by skilled investigator and subject matter experts.
- Document how complaint was handled, by whom and when, specifics of issue, departments involved & actions taken for follow up so issues can be closed.
- Have policy for how Hotline reporting or calls will be addressed. What is the identification, measurement, and prioritization of relevant events that may have a material consequence on the organization to achieve its objectives? ----- CORRECT ANSWER----------------Risk Assessment (having the right controls in place to provide quality care) A process effected by an entity's board of directors, management, and other personnel designed to provide reasonable assurance regarding the achievement of objectives is called....? -----CORRECT ANSWER----------------Internal Controls What are the "types" of internal controls? (tip: PDD) -----CORRECT ANSWER-------------- --1) Preventive (e.g. ask for permission before doing an action)
- Detective (e.g. Determine if you have an issue, audit trails for accessing a patient's record)
- Directive (e.g. put into place to advise like guidelines, P&P, training on the how to do)
Regarding Internal Controls - the requirement that purchases be made from suppliers on an approved vendor list is an example of a: a. Preventive control. b. Detective control. c. Compensating control. d. Monitoring control. -----CORRECT ANSWER----------------a. Preventive control - Preventive controls (asking permission before doing an action) are actions taken prior to the occurrence of transactions with the intent of stopping errors from occurring. Use of an approved vendor list is a control to prevent the use of unacceptable suppliers. Answer B is incorrect because a detective control identifies errors after they have occurred (e.g. audit trails for accessing patient's records) Answer C is incorrect because compensating controls are designed to supplement key controls that are either ineffective or cannot fully mitigate risks by themselves to acceptable levels. Answer D is incorrect because monitoring controls are designed to ensure the quality of the control system's performance over time Who has primary responsibility for the monitoring component of Internal controls? a. The organization's independent outside auditor. b. The organization's internal audit function. c. The organization's management. d. The organization's board of directors. -----CORRECT ANSWER----------------c. management! The organization's management has primary responsibility for the monitoring component of internal control. Answer A is incorrect because independent outside auditors perform financial statement audits to ensure that organizations meet their financial reporting obligations. Answer B is incorrect because the internal audit function performs an independent assessment of the system of internal controls. Answer D is incorrect because the organization's board of directors is responsible for governance and oversight, but not monitoring Objectives of Internal Controls -----CORRECT ANSWER----------------1) Reliability and Integrity of Information
- Compliance with Policies, plans, procedures, laws, regulations and contracts
- Safeguard Assets
- Econsomical and efficient use of resources
- Accomplishment of objectives and goals
True of False: A self-audit is an examination or inspection for providers in reducing non-compliance. Self-audits can lower chances of an external audit and create a robust culture of compliance -----CORRECT ANSWER----------------True Source: CHC Exam Secrets Study Guide CMS released areas of high-risk fraud, some of those include: A. Sudden changes in billing and billing inappropriate specialties B. Billing of inappropriate diagnoses and increased beneficiary complaints C. Geographical changes in billing and Identity theft (provider and beneficiary) D. A and B E. All of the above -----CORRECT ANSWER----------------E. All of the above At which level of the Medicare Part A or Part B appeals process is the appeal reconsidered by a qualified independent contractor? A. first level of appeal b. second level of appeal c. third level of appeal d. fourth level of appeal -----CORRECT ANSWER----------------b. second level of appeal 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 Ch Management responsibility as it pertains to risk, can be handled by implementing controls/techniques. -----CORRECT ANSWER----------------1) Avoid Risk
- Transfer Risk
- Accept Risk
- Reduce or Mitigate Risk True or False: The ACA requires that all providers adopt a compliance plan as a condition of enrollment with Medicare, Medicaid, and Children's Health Insurance Program (CHIP). - ----CORRECT ANSWER----------------True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) -----CORRECT ANSWER----------------1.Protect our programs 2.Protect your patients 3.Protect the Provider https://oig.hhs.gov/newsroom/podcasts/2011/heat/heat09- trans.asp#:~:text=Proper%20documentation%2C%20both%20in%20patients,to%20prot ect%20you%20the%20provider. At which level of the Medicare Part A or Part B appeals process is the appeal decision by the Office of Medicare Hearings and Appeals (OMHA)? a. first level of appeal b. second level of appeal c. third level of appeal d. fourth level of appeal -----CORRECT ANSWER----------------c.. third level of appeal Frist level - redetermination by Medicare contractor Second level - reconsideration by Independent contractor Third appeal - Administrative Law Judge (ALJ) hearing Fourth appeal - review by Medicare Appeals Council Fifth appeal - review in Federal District Court https://www.hhs.gov/about/agencies/omha/the-appeals-process/index.html What should CCO be able to do? (What skills should this person have?) Choose all that apply. a. Leadership skills. b. Oversee the coding department.
Also known as a BBA "three strikes rule" Which statement is TRUE regarding compliance programs? a. Compliance programs are considered more dangerous if they are developed but not implemented. b. Compliance programs can detect but not prevent criminal conduct c. Compliance programs are only required by law for healthcare entities that have more than $500,000 in annual revenue. d. Compliance programs are not mandated by law. -----CORRECT ANSWER---------------
- a. Compliance programs are considered more dangerous if they are developed but not implemented. Formal statement outlining a plan for a specified subject area. It usually cites state and/or federal required actions or standards. a. CAP b. Procedure document c. Policy document d. Legal standards -----CORRECT ANSWER----------------c. Policy document CAP - outlines corrective action plan Procedure - describes process/steps under a certain criteria Legal standards - mandatory action or rule Life cycle of records management -----CORRECT ANSWER----------------Creation Use Maintenance Retention Disposition Standards of Conduct (written P&Ps) -----CORRECT ANSWER----------------Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations Code of Conduct: Content Checklist -----CORRECT ANSWER----------------• Demonstrate system wide emphasis on compliance with all applicable laws and regulations
- Written plainly and concisely so all employees can understand the standards
- Includes internal and external regulations
- Mentions organizational policies without completely restating them
- Is consistent with company policies and procedures
- Includes management's responsibility to explain and enforce the code Ref: SCCE Compliance & Ethics Manual, Chapter 2 https://compliancecosmos.org/essential-elements-effective-ethics-and-compliance- program Code of Conduct and Employees -----CORRECT ANSWER----------------All employees must receive, read, and understand the standards. A supervisor should explain the standards and answer any questions. Employee should attest in writing that they have received, read, and understood the standards Employee compliance with standards must be enforced through appropriate discipline when necessary Discipline for non-compliance should be stated in the standards Code of Conduct Purpose -----CORRECT ANSWER----------------• To present specific guidelines for employees to follow
- To confirm that all employees comprehend what is required of them
- To provide a process for proper decision making
- To confirm that employees put standards into everyday practice
- To elevate corporate performance in basic business relationship
- To confirm that the organization upholds and supports proper compliance conduct Every organization needs policies and procedures for: -----CORRECT ANSWER---------- ------• Internal assessments
- Record retention (where, how long)
- Self-disclosure
- Medicare sanction checks (LEIE)
- Billing policies
- Credit balance
- No charge visits
- Incomplete/unsuccessful procedure
- Documentation requirements
- OIG calls for written evaluation to be presented to CEO, governing body, committee annually Non-retaliation in compliance - what is important to state in this policy: -----CORRECT ANSWER----------------For any reporting method to be effective, employees must accept that there will be no retaliation or retribution for coming forward. The concept of non-retaliation is fundamental to the compliance program, and a clearly stated policy regarding non-retribution is the first step.
- anonymous reporting and,
- no retaliation or retribution for bringing forth problems/concerns Place to start with Enforcement is: -----CORRECT ANSWER----------------Standards of conduct and P&Ps For Enforcement and Disciplinary Actions, Policies should include: -----CORRECT ANSWER----------------1. non-compliant consequences
- employees duty to report non-compliance
- list parties responsible for appropriate action
- outline of disciplinary actions or procedures
- promise that discipline will be fair and consistent New Employee Policy - three checks OIG recommends to do/perform: -----CORRECT ANSWER----------------OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? -----CORRECT ANSWER----------------Code of Conduct and P&Ps You are the new Compliance Officer, hired after ABC Hospital reorganized and decided that the General Counsel should no longer also serve in that role. Upon review of the Code of Conduct (CoC), you find that it is written using lots of legal jargon. What action do you take: a. Keep CoC as it is.
b. Pull a sample off the internet and insert hospital name to save time as it was most likely written by experts. c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance. d. Rewrite the CoC with detailed restating hospital's P&Ps, and all laws and regulations possible so that employees can't say they were not aware of requirements. ----- CORRECT ANSWER----------------c. Rewrite the CoC in plain and concise language tailored to the hospital so employees can use a general guidance. Explanation:
- CoC should be clear and concise language easy to understand, and should be tailored to specific issues of the organization What is the term called for an organization's commitment to compliance by the board, management, and employees? It summarizes ethical behavior and legal principles the healthcare organization operates. A) Code of Conduct B) Federal Sentencing Guidelines C) Internal Controls -----CORRECT ANSWER----------------A) Code of Conduct The U.S. Federal Sentencing Commission was organized in _____, published its initial set of guidelines in _____, and included chapter eight of the Federal Sentencing Guidelines for Organizations (FSGO) in _____. a. 1980, 1987, 1999 b. 1985, 1987, 1991 c. 1980, 1985, 1987 d. 1985, 1990, 2001 -----CORRECT ANSWER----------------b. 1985, 1987, 1991 "The privacy officer for a hospital has updated the Notice of Privacy Practices to reflect a material change because the previous notice did not have a description that individuals have the right to amend their Protected Health Information. The third party review team identified that the notice 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 have copies of the new NPP mailed to all patients seen within the last year at the hospital B. Make arrangements to have the new notice distributed to new patients that come to the hospital
d. None of the above -----CORRECT ANSWER----------------c. Unknowingly violating Medicare/Medicaid guidelines FRAUD is intentional (knowingly/willfully); WASTE is overuse/misuse of resources carelessly; ABUSE on the other hand, does not require poof of intent, but it's improper practice leading to unnecessary expenses A provider intentionally upcodes services to a higher level in order to receive a larger reimbursement from Medicare/Medicaid. Is this violation fraud, abuse, or neither? a. Fraud b. Abuse c. Neither -----CORRECT ANSWER----------------a. Fraud Upcoding - is a type of fraud (knowing/intentionally) coding more expensive codes for higher reimbursement What is true about Medicaid Integrity Programs: a. established by the DRA of 2005 b. federally administered and state monitored c. audited by MACs d. created to combat Medicare provider FWA -----CORRECT ANSWER----------------a. established by the DRA of 2005 (section 6034) https://www.ssa.gov/OP_Home/comp2/F109-171.html Notes: b. federally administered and state monitored (the opposite) c. audited by MACs (MIPs are audited by MICs) d. created to combat Medicare provider FWA (Medicaid, not Medicare) Reporting systems should be: a. marketed to contractors b. outsourced to a vendor c. operated by management d. publicized to all employees -----CORRECT ANSWER----------------d. publicized to all employees
Are providers financially liable if their billing services commit fraud without the provider's knowledge? Yes No -----CORRECT ANSWER----------------Yes - they are financially liable for all claims submitted on their behalf that contain their identification number Regarding patient credit balances, which of the following are good practices for addressing credit balance compliance risks: a. Review reporting capability as most EHRs can detect a credit balance issue. b. Perform root-cause analysis to determine the direct source of overpayment, and ongoing monitoring c. Perform random audits and report findings to ensure proper monitoring and corrective action. d. all of the above -----CORRECT ANSWER----------------d. all of the above Having a clear P&P on overpayments, self-disclosure and credit balances is also recommended to stay up to date with regulatory changes and avoid any penalties 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 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. d. Persons reporting fraud and abuse will be guaranteed another position if they are discharged from their current position. -----CORRECT ANSWER----------------c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions.
