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CHC Exam > Monitoring, Auditing, and Internal Reporting > Flashcards

Monitoring, Auditing, and Internal Reporting Flashcards

1
Q

What is Monitoring?

A

An ongoing process that assists management in ensuring their business processes is working as intended.

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2
Q

What is Auditing?

A

A formal, systematic, and methodical approach designed to evaluate and improve the effectiveness of business processes and controls.

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3
Q

TRUE/FALSE

Does the Compliance Officer and Staff have full access to all documents and other information that are relevant to compliance activities?

A

TRUE

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4
Q

TRUE/FALSE

The organization leadership and board of directors should be knowledgeable about the content and operation of the compliance program.

A

TRUE

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5
Q

Reviews (monitoring)

What are some techniques that the compliance officer or reviewer should consider when conducting a review?

A
  • On-site Visits
  • Testing of billing and coding staff on their knowledge of reimbursement and coverage criteria
  • Unannounced mock surveys, audits, and investigations
  • Check of personnel records to determine whether any individuals who have been reprimanded for compliance issues in the past are among those currently engaged in improper conduct
  • Interview with personnel involved in management, operations, coding claim submission, and other related activities
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6
Q

Reviews (monitoring)

What are some additional techniques that the compliance officer or reviewer should consider when conducting a review?

A
  • Questionnaires developed to solicit impressions of a broad cross-section of the organization’s employees and staff
  • Reviews of written materials and documentation prepared by the different departments
  • Trend analyses or longitudinal studies that seek deviations
  • Review of written materials and documentation prepared by the different divisions of an organization
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7
Q

How should the Compliance Officer and staff respond to reports of detected compliance offenses and violations?

A

Upon reports or reasonable indications of suspected noncompliance, it is important that the chief compliance officer or other management officials initiate prompt steps to investigate the conduct in question to determine whether a material violation of applicable law or the requirements of the compliance program has occurred, and if so, take steps to correct the problem

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8
Q

What should the records of an investigation for a detected compliance offense or violation include?

A

Records of the investigation should contain:

  • documentation of the alleged violation,
  • a description of the investigative process,
  • copies of interview notes and key documents,
  • a log of the witnesses interviewed and the documents reviewed,
  • the results of the investigation, e.g., any disciplinary action taken, and the corrective action implemented.
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9
Q

What are some resources that can be used to identify risk areas when developing annual work plans?

A

OIG Work Plan

Internal Findings related to other reviews

External Market Activity

External reviews done by enforcement agencies on a national basis

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10
Q

What are some components that the work plan can include?

A
  1. The audits to be performed;
  2. Audit schedules, including start and end dates
  3. Announced or unannounced audits;
  4. Audit methodology;
  5. Necessary resources;
  6. Types of Audit: desk or onsite;
  7. Person(s) responsible;
  8. Final audit report due date to compliance officer; and
  9. Follow-up activities from findings.
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11
Q

What key component of the work plan must be conducted after the final report?

A

A process for responding to all monitoring and auditing results and for conducting follow-up reviews of areas found to be non-compliant to determine if the implemented corrective actions have fully addressed the underlying problems.

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12
Q

Reviews (monitoring)

What are the six generic review activities that the OIG recommends that every organization has reviewed in place for?

A
  1. Claim Development and Submission Process
  2. Anti-kickback and Self-Referral Concerns
  3. Bad Debts
  4. Credit Balances
  5. Retention of Records
  6. Compliance Program Process
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13
Q

What are the minimum components that make up the format necessary to conduct a review or audit?

A
  1. Sample Selection
  2. Data Review and Collection
  3. Data Analysis
  4. Reporting Note: Compliance reviews should be designed as a form of ongoing process improvement.
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14
Q

What types of Sampling techniques are acceptable?

A

Sampling techniques for reviews may range from scientifically determined statistically valid to a modest review of data, depending on the purpose and end-user.

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15
Q

When should the organization use a sampling technique that is statistically significant?

A

When reporting a self-disclosure to and external agency to maintain credibility and objectivity

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16
Q

What are some reasons that cause corrective actions due to significant variations to the baseline found during a review or audit?

A
  1. Improper procedures
  2. Misunderstanding of the rules
  3. Fraud
  4. Systemic problems
17
Q

Are there instances when a significant variation would not prompt a corrective action plan?

A

Yes.

If the inquiry determines that the deviation occurred for legitimate, explainable reasons and has no significant impact, there may be limited corrective action or no action taken by management as a result of the findings.

18
Q

What are 3 general recommendations with the overall organizational reporting process of compliance?

A
  1. Organizational leadership and the Board of Directors should exercise reasonable oversight with respect to the compliance program’s implementation and effectiveness
  2. Compliance reports created by ongoing review should be maintained by the compliance officer and reviewed with senior management and the compliance committee
  3. A standard of macro comparisons across departments and functions should be developed and reported to senior leadership
19
Q

Audit

What 5 areas will conducting a Compliance Audit help with?

A
  1. Prevent, detect and deter criminal and unethical conduct
  2. Tailor a compliance program to an organization’s specific needs
  3. Improve the quality of the business functions of the organization
  4. Initiate immediate and appropriate corrective action by management
  5. Allow for early detection and reporting, thereby reducing loss
20
Q

Audit

Should the audit team conduct ongoing reviews for the organization?

A

No.

One value of a formalized audit is to provide an objective outside view of the organization’s process and the audit team should be a different team than those conducting ongoing monitoring.

21
Q

Audit

What are the 12 areas that OIG recommends that organizations have audits in place for?

A
  1. Specific risk areas by organization type
  2. Coding
  3. Billing
  4. Information systems audit
  5. Issues are resolved and not repeated
  6. Medical necessity
  7. Contract management
  8. Claims submission procedures, including enrollment
  9. Anti-kickback and self-referral concerns
  10. Bad debts
  11. Credit balances
  12. Advertising and marketing efforts
22
Q

What is one key difference between a review and an audit?

A

A consistent selection process and sampling procedure must be used for audits

23
Q

How often should audit reports be presented to the CEO, governing body, and compliance committee?

A

On a regular basis, but not less than annually

24
Q

How long does the compliance officer, compliance committee, or management official have to report instances to the appropriate governmental authorities of misconduct that appears to violate criminal, civil, or administrative law?

A

Within a reasonable time, but not more than 60 days after the misconduct is discovered Note: Attorney consultation is recommended

25
Q

When does the OIG require immediate notification to governmental authorities?

A

A clear violation of criminal law

The violation has a significant adverse effect on the quality of care provided to program beneficiaries

Indicates evidence of systemic failure to comply with applicable laws, an existing corporate integrity agreement, or other standards of conduct, regardless of the financial impact on federal health care programs Note: Attorney consultation is recommended

26
Q

Four components of a well-structured compliance self-assessment include?

A
  1. Specific to each organization type
  2. Forward-looking - linking into a long-term strategy for the organization
  3. Look for optimal compliance choice
  4. Be preventative in Nature
27
Q

What is the difference between a Self-Assessment and Needs-Assessment?

A

A needs assessment is the starting point for compliance risk identification, it maps out the initial plan. Self-assessment occurs after the organization’s compliance plan has been implemented and shows that the organization continues to value compliance and is “doing the right thing”.

28
Q

What is the key purpose for establishing a baseline assessment?

A

The “snapshot” or baseline is used as part of the benchmarking analysis and used by compliance and managers to judge the progress in reducing or eliminating potential areas of vulnerability and risk.

29
Q

To what extent can compliance protect anonymity and confidentiality?

A

Within legal and practical limits

30
Q

What are the recommended open lines of communication options available to report compliance issues?

A
  • Hotlines
  • Emails
  • Written Memos
  • Newsletters
31
Q

TRUE/FALSE

An “open door” policymaking a visible and vocal commitment to compliance for purposes of discussing compliance is an acceptable communication method to report compliance?

A

TRUE

32
Q

What policies must be enacted for communication and reporting purposes?

A
  • Ensuring the confidentiality of the information in the report and the individual making the report
  • List the steps of the investigatory process to ensure consistency and thoroughness
  • Guaranteeing that no retaliatory disciplinary actions will be taken against an individual making a “good faith” report
33
Q

TRUE/FALSE

The reporting mechanism for compliance issues must be publicized?

A

TRUE

Employee awareness is crucial if the reporting mechanism is to be effective

34
Q

What are some methods used to publicize the reporting mechanism?

A

Posters

Letters

Wallet cards

Newsletter articles

Code of Conduct

Other Compliance Communications

35
Q

OIG 7 Steps to an Effective Compliance Plan

A
  1. Conduct Internal Monitoring and Auditing
  2. Implement Compliance and Practice Standards
  3. Designation of a Compliance Officer/Contact(s)
  4. Conduct Appropriate Training and Education
  5. Respond Appropriately to Detected Violations (Have Written Policy)
  6. Develop Open Lines of Communication
  7. Enforce Disciplinary Standards Through Well-Publicized Guidelines

CHC Exam (10 decks)

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