Healthcare Compliance Programs and Regulations: A Guide for Physician Practices, Exams of Nursing

Download Healthcare Compliance Programs and Regulations: A Guide for Physician Practices and more Exams Nursing in PDF only on Docsity! 1 / 19 CPCO CERTIFICATION EXAM 70+ QUESTIONS AND ANSWERS 2023 2024 1. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, what is the name of the national program designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse? A. Health Care Fraud Prevention and Enforcement Action Team (HEAT) B. Health Care Recovery and Affordable Care Act (HCRAC) C. Health Care Fraud and Abuse Control Program (HCFAC) D. Health Care Civil Penalties Law: C. Health Care Fraud and Abuse Control Program (HCFAC) 2. According to the Federal Sentencing Guidelines, "To have an effective compliance and ethics program..., an organization shall exercise due diligence to prevent and detect criminal conduct." The FSGs also state organizations shall: A. Promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law. B. Implement mandatory compliance programs. C. Perform annual audits to detect criminal conduct. D. Immediately report evidence of misconduct to the authorities.: A. Promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law. 3. If a physician practice uses another entity's standards of conduct, the practice must: A. Implement the standards of conduct as received because they have already been approved. 2 / 19 B. Tailor those materials to the physician practice where they will be applied. C. Only select those standards that represent high risk issues for the practice. D. None of the above. Physician practices must create their own standards of conduct. It would be a compliance violation to copy another entity's standards of conduct.: B. Tailor those materials to the physician practice where they will be applied. 4. As the compliance contact for your physician practice, you are charged with developing the policies and procedures related to coding and billing. When developing these policies and procedures, which of the following statements should be included? A. If a new physician joins the practice and the new physician's NPI has not been received, services performed should be reported using the practice medical director's NPI. B. For any services billed, documentation must be present in the patient's medical record to support the services. C. To avoid compliance risk, coding for E/M services should be based solely on medical record documentation, even if it appears the level of service is not warranted. D. For denied services, billing staff should notify the physician to change the reported diagnosis to allow for resubmission and payment of the claim.: B. For any services billed, documentation must be present in the patient's medical record to support the services. 5. City Orthopedics, a large physician group practice employs several physician assistants and nurse practitioners. There have been several questions by the physicians on how incident to services should be billed. The compliance officer has called the Medicare Administrative Contractor for the practice and was given some information on how incident to services should be billed. Because the practice will be relying on the information received from the Medicare Administrative Contractor, what steps should the compliance officer take at the conclusion of the call according to the OIG Compliance Guidance for Individual and Small Group Physician Practices? A. Call someone else at the Medicare Administrative Contractor to confirm the information received. B. Send a letter to CMS to confirm the information provided by the Medicare Administrative Contractor is correct. C. Both A and B 5 / 19 A. A clearly defined chain of command for reporting potentially fraudulent conduct B. Guaranteed anonymity C. Well-publicized disciplinary actions for retaliation D. A policy that encourages reporting directly to the OIG: C. Well-publicized disciplinary actions for retaliation 13. What does the HHS OIG suggest as possible warning signs that non- compliance may exist? A. Significant change in the number or type of claim rejections. B. Getting carrier newsletters pertaining to the types of service that your practice bills. C. Consistent use of certain codes. D. Receipt of carrier requests for documentation.: A. Significant change in the number or type of claim rejections. 14. Having the ability to respond to issues enables a practice to develop effective action plans to correct problems and prevent future problems from occurring. What is one step that can be taken to establish compliance effectiveness for responding to and/or preventing compliance issues? A. Create a response team, consisting of representatives from the compliance and audit department. B. Create a response team, consisting of representatives from compliance, audit, and any other relevant functional department. C. Create an investigation team, consisting of representatives from compli- ance, audit, and any other relevant functional department. D. Create a prevention team, consisting of representatives from compliance, audit, and any other relevant functional department.: B. Create a response team, consisting of representatives from compliance, audit, and any other relevant functional department. 15. A physician office laboratory is authorized to perform urinalysis testing, including the microscopic analysis under their Provider-Performed Microscopy Procedures (PPMP) certification. It has been the physician's experience that many of his patients that have urinalysis testing done also requires the microscopic exam. Because of this and to be able to provide better treatment, he has established an office policy that for all urinalysis testing performed in his office, the lab should also perform the microscopic test. Is this a compliance risk? 6 / 19 A. Yes. Performing the microscopic test on all patients when the results of the urinalysis are negative could be considered medically unnecessary. B. Yes. The physician must always order the code for the urinalysis test with the microscopic exam to avoid unbundling. C. No. Because the physician is providing quality patient care, there is no compliance risk. D. No. The physici: A. Yes. Performing the microscopic test on all patients when the results of the urinalysis are negative could be considered medically unnecessary. 16. Billing companies should have written policies and procedures that reflect and reinforce Federal and State statutes. These policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the health care provider. Which of the following policies and procedures should a billing office have in place to meet these needs? A. Conclude that claims may be submitted when note has been started but not yet finalized by the physician as long as a signed affidavit is in place in the office granting the staff power to provide coding based on preliminary reports. B. Provide incentives to billing and coding staff in the form of compensation for productivity to ensure full revenue recovery of all claims in a timely fashion. C. Establish and maintain a process for pre- and post- submission review of claims to ensure claims submitted for reimbursement accurately represent services: C. Establish and maintain a process for pre- and post-submission review of claims to ensure claims submitted for reimbursement accurately represent services provided, are supported by sufficient documentation and are in conformity with any applicable coverage criteria for reimbursement 17. According to the OIG, medically unnecessary services should only be billed to Medicare in what circumstance? A. When directed to do so by the patient under ABN rules. B. To receive a denial so that the claim can be submitted to a secondary payer.C. When the provider is willing to submit the documentation to support the need for the service even though it is likely that Medicare will deny in any event. D. They should always be reported provided that an appropriate modifier is used to signal that the services are not medically necessary and should not 7 / 19 be covered.: B. To receive a denial so that the claim can be submitted to a secondary payer. 18. As part of a practice's compliance program, record retention policies and procedures should be developed. This policy and procedure should address the timeframes associated with the retention of various records. When developing a policy, which of the following statements should be present? A. Specific records must be retained based upon the most stringent require-ment identified in federal or state law, or internal policies and procedures. B. Records will be retained based upon federal requirements as this super- sedes state law or internal policies/procedures. C. Records will be retained based upon state requirements as this supersedes federal law or internal policies/procedures. D. Records will be retained based upon internal policies/procedures as this supersedes both federal and state laws.: A. Specific records must be retained based upon the most stringent requirement identified in federal or state law, or internal policies and procedures. 19. A patient being seen by a physician has unpaid medical bills in excess of $5,000 after insurance payments. The patient has now lost his job and has limited financial resources. The office manager has reviewed the patient's financial situation to assess the patient's ability to pay and has agreed to reduce the fees owed to $2,500. Would this act violate the OIG gift allowance for beneficiaries? A. Yes, the OIG gift allowance must be followed, even if a patient is unable to pay. B. Yes, by discounting the price to the patient, the practice must now increase fees to other payers, including Medicare, to make up the difference which is not allowed. C. No, this would be an exception to the OIG gift allowance because it is based on the patient's ability to pay. D. No, as long as the practice spreads out the fee reduction over more than one year.: C. No, this would be an exception to the OIG gift allowance because it is based on the patient's ability to pay. 20. Services furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are: 10 / 19 26. Dr. Appleton is an orthopedic surgeon in a large orthopedic practice. Due to the success of their clinic, the practice is opening a new orthopedic hospital that will be owned by all of the physicians in the group. In addition to Stark Law issues, what other compliance concern may be present? A. Dr. Appleton's referral of patients to the orthopedic hospital will violate the False Claims Act and subject him to the associated penalties and fines. B. Dr. Appleton and his colleagues will be paid a set amount of the profits, regardless of the value or volume of referrals. C. Dr. Appleton's ownership in the orthopedic hospital represents a conflict of interest because his decisions on the care needed by his patients may be biased by his potential financial gain for referring patients to the facility. D. There is no compliance concern. By opening a new orthopedic hospital, the practice is helping to assure needed orthopedi: C. Dr. Appleton's ownership in the orthopedic hospital represents a conflict of interest because his decisions on the care needed by his patients may be biased by his potential financial gain for referring patients to the facility. 27. Physician Quack just completed a 15-minute psychiatric evaluation of his patient. He intentionally completes his superbill for a 30-45-minute session. Dr. Quack may be liable for: A. Abuse B. Neglect C. Fraud D. None of the above: C. Fraud 28. The civil False Claims Act provides the Court with the authority to assess: A. One "times the amount of the damages which the Government sustains..." B. Up to two "times the amount of the damages which the Government sustains..." C. Up to three "times the amount of the damages which the Government sustains..." D. Up to four "times the amount of the damages which the Government sus-tains...": C. Up to three "times the amount of the damages which the Government sustains..." 29. The Federal Anti-Kickback Statute places certain constraints on business arrangements related directly or indirectly to items or services reimbursed by any Federal health care program, including, but not limited 11 / 19 to, Medicare and Medicaid. According to the OIG, which of the following would likely be an acceptable practice? A. A physician practice should participate in all aspects of a hospital's com- pliance program to be sure the anti-kickback statute is not violated. B. The hospital should oversee the physician practice's compliance program at no cost for the physicians in exchange for timely and accurate completion of inpatient records. C. The physician practice should limit participation in a hospital's compliance program to training and education or policies and procedures only. D. A hospital performs an annual claim audit for its affiliated physician prac- tices. There is no charge for the audit as the hospital inc: C. The physician practice should limit participation in a hospital's compliance program to training and education or policies and procedures only. 30. Although liability under the anti-kickback statute ultimately turns on a party's intent, it is possible to identify arrangements or practices that may present a significant potential for abuse. Which of the following questions would be helpful to determine whether a proposed action could violate the anti-kickback statute? A. Does the arrangement or practice have a potential to improve clinical decision-making? B. Does the arrangement or practice have a potential to decrease costs to Federal health care programs, beneficiaries, or enrollees? C. Does the arrangement or practice have a potential to decrease the risk of overutilization or inappropriate utilization? D. Does the arrangement or practice raise patient safety or quality of care concerns?: C. Does the arrangement or practice have a potential to decrease the risk of overutilization or inappropriate utilization? 31. Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) - Pub. L. 108-173, December 8, 2003 - authorized an exception to the physician self-referral prohibition for certain arrangements in which the physician can receive necessary non-monetary remuneration. What is this exception related to? A. Outpatient services B. E-Prescribing 12 / 19 C. Physician investments in specialty hospitals D. None of the above; there are no exceptions in the Stark law.: B. E- Prescribing 32. Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), is also known as the physician self-referral law and commonly referred to as the "Stark Law". The Stark Law applies to which of the following individuals or entities? A. Patients and their families B. Physicians and hospitals C. Federal health care programs like Medicare D. Both B and C: D. Both B and C 33. The Patient Protection and Affordable Care Act (PPACA) signed into law on March 23, 2010 mandated that all overpayments be returned within this amount of time post-identification? A. 15 days B. 45 days C. 60 days D. 75 days: C. 60 days 34. An office manager has misplaced his laptop. The hard drive on the laptop is not encrypted. Which of the following data stored on the laptop would be considered a HIPAA breach if someone gains access to the laptop? A. Employee immunization records B. Medicaid Reports listing patient names and dates of birth. C. Physician schedules for the operating room listing the physician's name and procedure done D. Health records of students: B. Medicaid Reports listing patient names and dates of birth. 35. Under the HIPAA privacy rule, which of the following situations would require an authorization from the patient to release records? A. A request from a life insurance company for the patient's medical records. B. A request from the patient's primary care physician to the surgeon regarding the patient's recent surgical procedure. C. A patient requests a copy of her lab work. 15 / 19 A. Dr. Hansen is part of a small group practice with Dr. Miller and three Physician Assistants. Dr. Miller is retiring and leaving the practice. Dr. Hansen is listed on the CLIA certificate as the owner/medical director. B. Family Foundation is a medical group focusing on family practice/pediatric care. They received a notice in the mail that it's time to renew their CLIA certificate. C. Good Care medical clinic is excited to be moving to a new location. It is a brand new building right across the street from their current location. They chose this location because it would be the most convenient for their patients. D. When a new test is performed that is not covered under the practice's current CLIA certificate.: C. Good Care medical clinic is excited to be moving to a new location. It is a brand new building right across the street from their current location. They chose this location because it would be the most convenient for their patients. 44. Any health care fraud scheme that disseminate any article or document through a "common mail carrier" may be the basis for a charge of: A. Mail Fraud B. Wire Fraud C. Mail Fraud and Wire Fraud D. False Claims: A. Mail Fraud 45. When agreeing to a global civil fraud settlement, what is the most popular reason why a provider agrees to enter into a Corporate Integrity Agreement? A. To avoid exclusion from participation in Federal health care programs B. To obtain a Civil Monetary Penalty reduction C. To obtain a fine reduction D. To avoid incarceration: A. To avoid exclusion from participation in Federal health care programs 46. A new orthopedic physician is being hired in a group practice. The group has been searching for quite a while and finally found the perfect candidate. As part of the practice's hiring process, employees must be checked against the OIG and GSA lists for excluded parties. Does this practice also apply to physicians? A. No, this requirement only applies to non-medical employees of the practice. 16 / 19 B. No, this requirement only applies to non-medical employees of the practice and vendors. C. Yes, this requirement only applies to physicians. D. Yes, this requirement applies to physicians and employees of the practice.- : D. Yes, this requirement applies to physicians and employees of the practice. 47. A physician practice hired a consultant to perform external audit services for their practice. After the consultant began working, the OIG and GSA lists were checked and it was found the consultant was excluded from participation. What steps should the practice take? A. Nothing. Because the consultant is not ordering, referring, or performing medical services, there is no problem. B. Report the consultant to the OIG for violating her exclusion status. C. Immediately ask the consultant to stop work. D. Contact legal counsel. E. Both C and D: E. Both C and D 48. Which entity provides benefit integrity investigations based on billing abnormalities identified by data analysis or allegations of fraud and abuse, as well as conducts reviews that will allow them to compare billing of Medicare claims to Medicaid claims known as the "Medi-Medi" program that helps to identify fraudulent activity between the two programs? A. Medi-Medi Audit Contractors (MACs) B. Recovery Audit Contractors (RACs) C. Medicaid Integrity Contractors (MICs) D. Zone Program Integrity Contractors (ZPICs): D. Zone Program Integrity Contractors (ZPICs) 49. Federal and state investigators are in the process of identifying and copying documents that are identified in the Government's search warrant. Which of the following statements are true regarding document protection? A. Employees should not destroy, change or alter any documents, including paper, tape and electronic records because such actions can lead to criminal liability. B. Documents should not be moved but it is ok to amend records in an attempt to correct the information in them. 17 / 19 C. Let the investigator know that some documents will be destroyed because the office policy on routine record destruction cannot be suspended. D. You do not have to give the investigator computer access if you don't want to.: A. Employees should not destroy, change or alter any documents, including paper, tape and electronic records because such actions can lead to criminal liability. 50. CMS' Self-Referral Disclosure Protocol (SRDP) sets forth a process for providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute (section 1877 of the Social Security Act). Which of the following statements are true about the SRDP? A. The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party's reasonable assessment are actual or potential violations of the physician self-referral statute. B. Participation in the SRDP is only limited to physicians. C. Disclosing parties can disclose the same conduct under both the SRDP and the OIG's Self-Disclosure Protocol. D. To facilitate CMS' verification and validation processes, CMS requires access to all financial statements, notes, disclosures and other supporting documents regardless of the assertion of privileges or limitations on the information produced.: A. The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party's reasonable assessment are actual or potential violations of the physician self-referral statute. 51. Responsible for the overall fulfillment of the OIGs mission and for promoting effective management and quality of the agency's proceesses and products.: Immediate Office of the Inspector General 52. Performs independent audits of HHS programs and/or HHS grantees and contractors to examine their performance.: Office of Audit Services 53. Provide's mission and administrative support to the OIG.: Office of Management and Policy 54. Conducts national evaluations of HHS programs from a broad issue- based perspective.: Office of Evaluation and Inspections 55. Conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries. They also operate an OIG hotline.: Office of Investigations 56. Provides legal advocacy and counsel to the Inspector General and OIG's other components.: Office of Counsel to the Inspector General