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HCCA- CHC EXAM, PRACTICE EXAM AND STUDY
GUIDE NEWEST 2024 ACTUAL EXAM 500+
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH EXPLANATIONS (VERIFIED ANSWERS)
|ALREADY GRADED A+
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). ✔✔True ref. ACA section 6102 According to HHS-OIG - what are three important reasons for proper documentation in Compliance? (hint: protections) ✔✔1.Protect our programs
- Protect your patients
- Protect the Provider https://oig.hhs.gov/newsroom/podcasts/2011/heat/heat09- trans.asp#:~:text=Proper %20documentation%2C%20both%20in%20patients,to%20protect%20y ou%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 ✔✔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. c. Skills to design and implement a compliance program. d. Be able to anticipate new risk areas.
a. ensuring leadership reads the policies b. increasing management involvement c. responding to compliance hotline calls d. monitoring the code of conduct ✔✔b. increasing management involvement Which of the following requires providers to be permanently excluded from all federal health care programs if found guilty of a healthcare related fraud a third time: a. Deficit Reduction Act of 2005 b. False Claims Act c. Balance Budget Act of 1997 d. Social Security Act section 1128 ✔✔c. Balance Budget Act of 1997 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. ✔✔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 ✔✔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 ✔✔Creation Use Maintenance Retention Disposition
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 ✔✔• 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: ✔✔• 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
When should Code of Conduct be distributed to new employees? ✔✔Must be distributed within 90 days of hire RAT-STATS is: (select all that apply) a. statistical software to select randomized samples b. government statistical rule software developed in the 1970s c. free hospital statistical software d. recommended by OIG, CMS and other agencies to select random samples ✔✔a. b. d. The software can be used by other entities other than hospitals, so option "c." is not precisely accurate, but it is free to use and can be downloaded here: https://oig.hhs.gov/compliance/rat- stats/index.asp What is the term called for an organization's commitment to compliance by management, employees, and contractors. Statement should summarize ethical behavior and legal principles under which the healthcare organization operates? ✔✔Code of Conduct In the course of an audit, you find that disciplinary actions against certain physicians and high level executives for non-compliance in the organization have been unfair and inconsistent with current policies & procedures. What is your first course of action .a. Work with legal counsel to enforce proper disciplinary actions
- anonymous reporting and,
- no retaliation or retribution for bringing forth problems/concerns Place to start with Enforcement is: ✔✔Standards of conduct and P&Ps For Enforcement and Disciplinary Actions, Policies should include: ✔✔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: ✔✔OIG recommends: perform background checks, reference checks, and exclusion list checks Which two main documents become tools to build compliance program? ✔✔Code of Conduct and P&Ps What is the ultimate goal of having a Compliance Program in place? a. ensuring coders and billers are properly trained to ensure compliance with the FCA
b. detecting and preventing misconduct c. auditing and monitoring key hospital department areas to mitigate risks identified d. aligning organizational compliance efforts with legal and HR ✔✔b. detecting and preventing misconduct 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. ✔✔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
hospital C. Post a copy of the new notice 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 the OCR that the hospital was in violation of the NPP requirements and has since corrected the deficiency ✔✔B. Make arrangements to have the new notice distributed to new patients that come to the hospital Remember: 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.
- The right to receive an accounting of disclosures of PHI as provided by § 164.528.
- The right to receive a paper copy of the NPP upon request.
- A brief description of how the individual may exercise the foregoing rights, e.g., by submitting a written request to the provider's privacy officer. What is the best definition of Medicare/Medicaid fraud? a. Attempting a scheme against the Medicare/Medicaid program b. Knowingly executing a scheme against the Medicare/Medicaid program c. Willfully executing a scheme against the Medicare/Medicaid program d. All of the above ✔✔d. All of the above Remember: Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme. FRAUD is intentional; 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 What is the best definition of Medicare/Medicaid abuse? a. Knowingly defrauding the Medicare/Medicaid program b. Intentionally violating Medicare/Medicaid guidelines c. Unknowingly violating Medicare/Medicaid guidelines d. None of the above ✔✔c. Unknowingly violating Medicare/Medicaid guidelines
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 ✔✔d. publicized to all employees Are providers financially liable if their billing services commit fraud without the provider's knowledge? Yes No ✔✔Yes - they are financially liable for all claims submitted on their behalf that contain their identification number
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 ✔✔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. ✔✔c. Persons reporting fraud and abuse who are discharged, demoted, suspended, harassed, or discriminated against have protection from such actions. The entity's level of commitment to compliance is directly related to the resources (human and financial)
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 Ch 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 ✔✔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 Ch Which department is the largest inspector general's office in the federal government?
a. HHS Office of Inspector General b. Office of Civil Rights c. Department of Justice d. Centers for Medicare & Medicaid Services ✔✔a. HHS Office of Inspector General Note: practice question from AAPC CPCO Ch What term would be used for actions that, either directly or indirectly, results in unnecessary costs to the Medicare program? a. Fraud b. Mistake c. Waste d. Abuse ✔✔d. Abuse Abuse - Abuse is similar to fraud, except that the investigator cannot establish the act was committed knowingly, willfully, and intentionally. The difference between fraud and abuse is the individual's intent. Fraud - knowingly/intentionally Waste - overuse/misuse of resources Note: practice question from AAPC CPCO Ch
