Test Flashcards
Compliance Program primary concern
rules and regulations
Integrity Program primary concern
values; doing the right thing
Who needs a compliance program?
Physicians Practices Medicare + Choice Organizations Ambulance Suppliers Third Party Billing Companies Pharmaceutical Manufacturers Hospitals Laboratories Teaching Institutions/Research DME Distributors Home Health/Hospice/SNF Others
Defense Industry Initiative
Voluntary self-regulatory guidelines developed by defense industries suppliers
GOAL: Eliminate waste and bring prices into line
Who is responsible for enforcing the rules and regulations under the Medicare and Medicaid laws
HHS OIG in conjunction with the Justice Department
An effective compliance program:
safeguards the organization’s legal responsibility to abide by applicable laws ad regulations
Three strikes and you’re out
Balanced Budget Act of 1997
Qui Tam
whistle blower
This act provides financial incentives for private citizens to come forward in qui tam suite
False Claims Act (FCA)
He who brings the action for the king as well as for himself
Qui tam pro domino rege quam pro se ipso in hac parte sequitur
Qui tam pro domino rege quam pro se ipso in hac parte sequitur
He who brings the action for the king as well as for himself
Healthcare whistle blowers can be eligible to receive X of government’s total award if DOJ decides to assume the case
15-25%
Healthcare whistle blowers can be eligible to receive X of government’s total award if DOJ declines the case
25-30%
Who can impose a CIA (corporate integrity agreement)
The government
CIA characteristics
negotiated in order to avoid litigation admits no fault or liability submits to government for corrective action 3-5 year duration extensive reporting requirements
Fine for organizations are calculated using:
Culpability score
Possible sanctions include
fines, restitution, forfeiture, and probation
Factors that might mitigate an organization’s punishment
effective ethics program and self reporting, cooperation or acceptance of responsibility
Four aggravating factors to a culpability score
if upper level employee has “participated in, condoned, or was willfully ignorant of the offence”
if the violation is a repeat offense
if the government was hindered during its investigation
if awareness of and tolerance of the violation were pervasive
Four mitigating factors in a culpability score
If the organization had an effective compliance program, even though there was a violation
If the organization reported the violation promptly
If the organization cooperated with the government investigators
If the organization accepted responsibility for the violation
Seven Elements of an effective compliance program
- Written standards of conduct
- Designating a chief compliance officer and other appropriate bodies
- effective education and training
- Audits and evaluation techniques to monitor compliance
- Reporting processes and procedures for complaints
- Appropriate disciplinary mechanisms
- Investigation and remediation of systemic problems
Ten Obstacles to Effective compliance Implementation
- Commitment and buy-in
- Lack of funding
- Too many roles for compliance professional
- Interpreting laws and regulations
- Lack of resources and staff
- Lack of education and training
- Resistance to change
- Lack of or poor communication
- Fear of retaliation/retribution
- No internal enforcement
which two documents become tools to build compliance program
the standards or code of conduct and the polices and procedures
When a patient requests access to PHI, the covered entity can:
a. Take up to 120 days to respond
b. Charge for retrieving the record
c. Require that the request be in writing
d. Request the patient accept a summary of the record
c. Require that the request be in writing
Changes to the Privacy and Security provisions of the HIPAA and its regulations were enacted in which of the
following acts?
a. GINA
b. FERA
c. FACTA
d. HITECHD. HITECH
Appropriate progressive discipline policies associated with a compliance program should be:
a. Defined by role
b. Enforced consistently
c. Applied to physicians
d. Reported to the government
b. Enforced consistently
At which level of the Medicare Part A or Part B appeals process is the appeal reconsidered by a qualified independent contractor? A. first level of appeal b. second level of appeal c. third level of appeal d. fourth level of appeal
b. second level of appeal
True or False:
An oral request by law enforcement may delay notifications related to a breach for up to 60 days.
False
True or False:
An individual has the right of access all information maintained in that individual’s Designated Record Set.
False
An individual has the right of access to the PHI maintained within a Designated Record Set (DRS), not all of the information maintained in the DRS.
True or False:
Minimum necessary requirements under HIPAA does not apply to uses or disclosures required by law.
Answer: True
Disclosures required by law are subject to the minimum necessary requirement.
True or False:
A CE must accommodate reasonable requests by an individual to receive communications of PHI by alternative means.
Answer: True
This is directly from the regs…if reasonable, then the CE must accommodate.
True or False:
Privacy means the property that data or information is not made available or disclosed to unauthorized persons or processes.
Answer: False
The definition listed is verbatim that which applies to security.
