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 Ins... [Show More] urance 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
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%20protect%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
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.
e. Practical experience with documenting medical necessity.
a. Leadership skills,
c. Skills to design and implement a compliance program, and
d. Be able to anticipate new risk areas.
Which of the following is an absolute necessity in order to have a successful Compliance Program?
a. continuous training and improvements
b. effective reporting path
c. non-retaliation for whistleblowers
d. reliable and equal discipline
c. non-retaliation for whistleblowers
A Compliance Program with well written policies and procedures:
a. can be successful if consistently reviewed and maintained
b. cannot be effective due to the sheer volume presented
c. will be effective if read by management
d. will not be successful without the proper oversight
d. will not be successful without the proper oversight
A Compliance Officer can achieve a higher level of compliance and ethics engagement by:
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
Standards of Conduct (written P&Ps)
Demonstrate the organization's ethical attitude and its "enterprise-wide" emphasis on compliance with all applicable laws and regulations
Code of Conduct: Content Checklist
• 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
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
• 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
b. Get HR involved and recommend the use of progressive discipline policies
c. Immediately terminate these individuals
d. Get local and federal labor department involved for unfair discipline.
b. Get HR involved and recommend the use of progressive discipline policies
OIG recommends setting forth the degrees of disciplinary actions. Progressive discipline provides a structure and a set of discipline standards for managers/supervisors to follow to ensure discipline is fair, equitable and consistent.
Documentation
• A&M should be documented
• Findings should be shared with dept managers
• If activity is part of risk priority then compliance committee, senior leadership and board when necessary
• 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:
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:
Standards of conduct and P&Ps [Show Less]
