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Chapter | 8 |Federal |Sentencing |Guidelines |(FSG) |- |CORRECT | ANSWERS |✔✔Guidelines |and |policy |in |this |section |apply |to | sentencing |in |federal |criminal |prosecution |when |the |convicted | defendant |is |an |organization FSG- | 4 |factors |that |increase |ultimate |punishment |of |an | organization |- |CORRECT |ANSWERS |✔✔1.Involvement |in |or |tolerance | of |criminal |activity | 2.Prior |history |of |the |organization | 3.The |violation |of |an |order 4.The |obstruction |of |justice FSG- |The |two |factors |that |mitigate |the |ultimate |punishment |of |an | organization |- |CORRECT |ANSWERS |✔✔1.The |existence |of |an | effective |compliance |and |ethics |program |
- |Self-reporting,cooperation, |or |acceptance |of |responsibility FSG |- |The | 4 |general |principles |- |CORRECT |ANSWERS |✔✔1. |The | court |orders |the |organization |to |remedy |harm |caused |by |the | offense. 2.If |the |organization |operated |primary |for |a |criminal |purpose |or | primarily |by |criminal |means |the |fine |should |divest |it |of |all |assets.
- |Fine |based |on |seriousness |and |culpability |(6 |factors)
- |Probation |is |appropriate |when |needed |to |ensure |another | sanction |is |fully |implemented |or |to |ensure |steps |will |be |taken |to | reduce |likelihood |of |future |offense. FSG-High-level |personnel |of |the |organization |- |CORRECT |ANSWERS | ✔✔Individuals |who |have |substantial |control |over |the |organization | or |who |have |a |substantial |role |in |the |making |of |policy |or |has | substantial |ownership |interest FSG-Substantial |authority |personnel |- |CORRECT |ANSWERS | ✔✔Individuals |who |within |the |scope |of |their |authority |exercises | substantial |measure |of |discretion |in |acting |on |behalf |of |an | organization. |High-level |included |in |definition |. |Examples | manager,can |negotiate |contracts |or |prices, |supervisory |authority. | No |of |these |examples |is |required, |determined |on |a |case |by |case | basis. FSG-Condoned |- |CORRECT |ANSWERS |✔✔If |individual |knew |of |the | offense |and |didn't |take |reasonable |steps |to |prevent |or |terminate | the |offense. FSG- |willfully |ignorant |of |the |offense |- |CORRECT |ANSWERS |✔✔If | the |individual |did |not |investigate |the |possible |occurrence |of | unlawful |conduct |despite |knowledge |of |circumstances |that |would | lead |a |reasonable |person |to |investigate.
FSG-Compliance |and |ethics |program. | 4 |factors |to |consider |in | meeting |requirements |- |CORRECT |ANSWERS |✔✔A). |Applicable | Government |Regulation |and |Industry |Practice | B).Size |of |the |organization | C).Recurrence |of |similar |misconduct FSG-Small |Organization |- |CORRECT |ANSWERS |✔✔<200 |employees FSG-Pervasiveness |under |subsection |b. |- |CORRECT |ANSWERS | ✔✔Case |specific, |depends |on |number |and |degree |of |responsibility, | of |individuals |within |substantial |authority |personnel |who | participated |in,condoned, |or |were |willfully |ignorant |of |the |offense. Obstruction |does |not |apply |to |- |CORRECT |ANSWERS |✔✔Individuals | hiding |from |organization 5 |most |important |federal |fraud |and |abuse |laws |- |CORRECT | ANSWERS |✔✔*False |Claims |Act |(FCA) *Ant |- |kickback |Statute |(AKS) Physician |Self-referral |Law |(Stark |I |II |III |) *Exclusion |Authorities *Civil |Monetary |Penalties |Law |(CMPL)
Stark |- |designated |health |services |(DHS) |- |CORRECT |ANSWERS | ✔✔*labs *PT,OT,Outpatient |Speech/Language |Pathology | *Radiology, |some |other |imaging *Radiation |therapy, |supplies *DME *Parenteral |enteral |nutrients |supplies *Prosthetic |Orthotic |supplies |devices *Home |Health |services *Outpatient |Rx |drugs *Inpatient |and |Outpatient |Hospital |Services Stark |- |strict |liability |- |CORRECT |ANSWERS |✔✔Proof |of |intent |not | required |to |prosecute Stark |- |CORRECT |ANSWERS |✔✔Prohibits |physicians |from |referring | patients |to |receive |DHS |payable |by |Medicare |or |Medicaid |from | entities |with |which |the |physician |or |immediate |family |member |has | a |financial |relationship |unless |an |exception |applies. Stark-penalties |- |CORRECT |ANSWERS |✔✔Fines |and |exclusion |from | federal |healthcare |programs.
families |with |income |above |100% |and |at/below |150% |of |FPL. |Also | requires |payment |of |alternative |premiums |as |a |condition |of | eligibility |and |alternative |cost |sharing |as |a |condition |of |receipt |of | the |service |or |drug |or |cost |sharing |of |non-emergency |services |in | ER. |Not |to |exceed |5% |of |family |income |fir |the |month |or |quarter | period. DRA-LTC |=Long |Term |Care |- |CORRECT |ANSWERS |✔✔LTC |Partnership | is |a |unique |combination |of |private |insurance |and |special |access |to | Medicaid |while |still |protecting |assets. DRA-MFP=Money |Follows |the |Person |- |CORRECT |ANSWERS | ✔✔Section | 6071 |supports |states |in |rebalancing |LTC |through | 5 | years |if |competitive |grants |that |support |targeted |reforms |to | strengthen |community-based |infrastructure DRA- |Transfer |of |Assets |- |CORRECT |ANSWERS |✔✔Sections |6011- 6016 |include |several |provisions |to |discourage |"Medicaid |Planning". DRA- |Documentation |of |Citizenship |- |CORRECT |ANSWERS | ✔✔Section | 6036 |requires |states |to |obtain |proof |of |Citizenship |and | identity |in |order |to |receive |Federal |Financial |Participation |(FFP). DRA-Health |Opportunity |Accounts |- |CORRECT |ANSWERS |✔✔Section | 6082 |allows |for | 10 |states |to |deliver |Medicaid |benefits |through |an |
Health |Opportunity |Account |(HOA) |in |combo |with |high |deductible | health |plans DRA- |3rd |Party |- |CORRECT |ANSWERS |✔✔Section | 6035 |enhance | state's |ability |to |find |and |recover |3rd |party |liabilities |primary |to | Medicaid DRA-MIP=Medicaid |Integrity |Program |- |CORRECT |ANSWERS | ✔✔Section | 6032 |requires |entities |that |receive |or |make |payments |of | 5 |mil |annually |to |provide |Federal |False |Claims |Act |education |to | employees. |MIP |was |formed |by |section | 6034 |with |more |resources | for |CMS |to |use |to |fight |Medicaid |Fraud, |Waste, |& |Abuse. DRA-HCBS |(Home |and |Community-Based |Services) |Waiver |- | CORRECT |ANSWERS |✔✔States |can |amend |their |state |plans |to |offer | HCBS |as |a |State |Plan |Optional |Benefit |(SPO) |This |allows |states |to | offer |most |services |now |covered |under |the |waiver |except |"other | services |". |New |DRA |option |breaks |eligibilty |link |between |HCBS |and | institutional |care. False |Claims |Act |(FCA) | 31 |USC |sections |3729-3733 |- |CORRECT | ANSWERS |✔✔Enacted |in | 1863 |due |to |concerns |suppliers |to |Union | Army |were |defrauding |the |Army. |States |any |person |who | knowingly |makes |a |false |claim |to |gov |is |liable |for |treble |the |claim |plus |$5k-$10k |(raised |over |the |years) |per |false |claim
4 |. |Education | 5 |Monitoring |
- |Enforcement | 7.Response |and |Prevention HCCA- |Evaluation |and |Measurement | 2 |dimensions |- |CORRECT | ANSWERS |✔✔ 1 |. |EFFORT |
- |OUTCOMES HCCA- |effort |- |CORRECT |ANSWERS |✔✔Time |money |resources | commitment HCCA-outcomes |- |CORRECT |ANSWERS |✔✔Impact |efforts |have |had | on |level |of |compliance FCA |- |LIABILITY |- |CORRECT |ANSWERS |✔✔Knowingly |submits,causes | another |to |submit |a |false |claim,or |knowingly |makes |a |false |record | or |statement |to |get |a |false |claim |paid |by |government. |Conspire |to | to |violate |FCA. |Also |see |reverse |FC |section FCA |- |LIABILITY |cont |"Reverse |false |claim |section |" |- |CORRECT | ANSWERS |✔✔Act |improperly |to |avoid |having |to |pay |government.
FCA |- |DAMAGES |and |PENALTIES |- |CORRECT |ANSWERS |✔✔Fines |of | $5k- |10k |(varies |due |to |adjustments |) |/claim |plus |treble | government |damages |unless |self-reported |then |under |certain | circumstances |not |less |than |double |government |damages FCA-Knowledge |requirement |- |CORRECT |ANSWERS |✔✔3729(b)(1) |
- |Actually |knowledge | 2 |. |Deliberate |ignorance |of |truth |or |falsity |of |information | 3.Reckless |disregard |for |of |the |truth |or |falsity |of |the |information FCA-"claim" |- |CORRECT |ANSWERS |✔✔Demand |for |money |or |property |made |to |Federal |Government |or |contractor,grantee,or |other | recipient |if |the |money |is |spent |on |the |government's |behalf |and |if | Federal |Government |provides |any |of |the |money |demanded |or |if | the |Federal |Government |will |reimburse |the |contractor |or |grantee. | Doesn't |apply |to |tax |claims FCA |- |qui |tam |provision |- |CORRECT |ANSWERS |✔✔Allows |private | persons |to |file |suit |for |violations |of |FCA |on |behalf |of |the | government. FCA-"relator" |- |CORRECT |ANSWERS |✔✔Person |bringing |qui |Tam |suit
*Promote |understanding |of |compliance |program, *Employees |understand |their |role |in |compliance |process *Demonstrate |organizational |comitment |to |compliance |efforts | *Communicate |industry |standards HCCA |-Education |: "Structural |vs |substantive |- |CORRECT |ANSWERS |✔✔1. |Structural, | how |compliance |program |operates |
- |Substantive, |specific |laws |and |regulations |that |directly |impact | organization "ERISA" |- |CORRECT |ANSWERS |✔✔Employment |Retirement |Income | Security |Act |of | 1974 ERISA-amendnents |- |CORRECT |ANSWERS |✔✔COBRA |,HIPAA,Mental | Health |Parity |Act,Newborn |and |Mother's |Health |Protection | Act,Womens |Health |and |Cancer |Right |Act ERISA |- |OVERVIEW |- |CORRECT |ANSWERS |✔✔Federal |Law |that |sets | minimum |standards |for |retirement |and |health |benefit |plans |in | private |industry. ERISA |- |"employee |welfare |benefit |plan" |- |CORRECT |ANSWERS | ✔✔Medical |surgical,or |hospital |care |benefits |or |benefits |in |the |
event |if |sickness,accident |disability, |death,or |unemployment |or | vacation |benefits. |(Not |pension |) ERISA |-Fiduciary |Duties |- |CORRECT |ANSWERS |✔✔1.The |assets |of |an | employee |welfare |benefit |plan |must |be |held |in |trust |by |one |or | more |trustee 2.Trustee |must |discharge |duties |solely |in |the |interest |of |the |plans | participants |and |beneficiaries |
- |Must |be |maintained |and |established |pursuant |to |a |written | instrument |which |names |one |or |more |fiduciaries |who |have | authority |and |control |of |plan |operations 4 |. |fiduciaries |must |diversify |the |the |investments |and |not |engage | in |non-exempt |transactions.
- |Fiduciaries |must |act |prudently |and |can |be |held |liable |for |a | breach |of |duty GINA-"Genetic |Information |,Nondiscrimination |Act |of |2008" |- | CORRECT |ANSWERS |✔✔GINA-Protects |against |Genetic | discrimination |re |employment |and |health |insurance GINA- | 2 |PARTS |- |CORRECT |ANSWERS |✔✔ 2 |Parts |1. | Title |I.prevents |discrimination |regarding |health |insurance | Title |2. |prevents |discrimination |regarding |employment
AKS |- |FCA |relationship |- |CORRECT |ANSWERS |✔✔The |Patient | Protection |and |Affordable |Care |Act |of | 2010 |expanded |the |liability | of |the |False |Claims |Act |to |now |definitively |include |Anti-Kickback | claims |as |grounds |for |violation. |Prior |to |the |healthcare |reform, |it | was |unclear |whether |or |not |Anti-Kickback |claims |constituted |a | violation |of |the |False |Claims |Act. SOX- |"Sarbaynes-Oxley |Act |of |2002. |- |CORRECT |ANSWERS | ✔✔mandated |a |number |of |reforms |to |enhance |corporate | responsibility, |enhance |financial |disclosures |and |combat |corporate | and |accounting |fraud, |and |created |the |"Public |Company | Accounting |Oversight |Board," |also |known |as |the |PCAOB, |to |oversee | the |activities |of |the |auditing |profession. SOX-CORP |Responsibility |- |CORRECT |ANSWERS |✔✔SOX |Section | 302 |- |Corporate |Responsibility |for |Financial |Reports a) |CEO |and |CFO |must |review |all |financial |reports. b) |Financial |report |does |not |contain |any |misrepresentations. c) |Information |in |the |financial |report |is |"fairly |presented". d) |CEO |and |CFO |are |responsible |for |the |internal |accounting | controls. e) |CEO |and |CFO |must |report |any |deficiencies |in |internal | accounting |controls, |or |any |fraud |involving |the |management |of |the | audit |committee. f) |CEO |and |CFO |must |indicate |any |material |changes |in |internal | accounting |controls.
SOX- |Internal |Controls |- |CORRECT |ANSWERS |✔✔SOX |Section |404: | Management |Assessment |of |Internal |Controls All |annual |financial |reports |must |include |an |Internal |Control |Report | stating |that |management |is |responsible |for |an |"adequate" |internal | control |structure, |and |an |assessment |by |management |of |the | effectiveness |of |the |control |structure. |Any |shortcomings |in |these | controls |must |also |be |reported. |In |addition, |registered |external | auditors |must |attest |to |the |accuracy |of |the |company | management�s |assertion |that |internal |acc PPACA |-Coverage |- |CORRECT |ANSWERS |✔✔*Can't |deny |coverage |to | children |under | 19 |due |to |preexisting |condition *Can |stay |on |parents |coverage |until | 26 *Insurance |can't |rescind |coverage |due |to |honest |mistake |on | application. |Must |provide | 30 |day |notice |prior |to |cancelation | Right |to |appeal |denial |through |internal |or |external |appeal. | Insurer |must |provide |info |on |appeal |and |State |Consumer |Assistance |Progrm PPACA |-Cost |- |CORRECT |ANSWERS |✔✔SOX |Section |404: | Management |Assessment |of |Internal |Controls All |annual |financial |reports |must |include |an |Internal |Control |Report | stating |that |management |is |responsible |for |an |"adequate" |internal | control |structure, |and |an |assessment |by |management |of |the | effectiveness |of |the |control |structure. |Any |shortcomings |in |these |
