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CHC Exam > Test Questions > Flashcards

Test Questions Flashcards

1
Q

At which level of the Medicare Part A or Part B appeals process is the appeal reconsidered by a qualified independent contractor?

A

Second level of appeal.

There are five levels to the appeal process.

  1. Redetermination of the claim by a Medicare administrative contractor, fiscal intermediary, or Medicare carrier.
  2. Reconsideration by a qualified independent contractor (QIC).
  3. Hearing overseen by an administrative law judge in the office of Medicare hearings and appeals.
  4. Review by the Medicare Appeals Council.
  5. Judicial review in federal district court.
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2
Q

If an at-risk patient is left unattended and has an adverse response to medication, this is known as a(n)…

A

Sentinel event

A sentinel event is an adverse occurrence that is not in the normal progression of a patient’s illness. Whenever a sentinel event occurs, the healthcare facility should perform a root cause analysis.

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3
Q

A behavioral health specialist notices a particularly high number of restraint deaths at a facility. An analysis of the root causes of these events is most likely to indicate problems with…

A

Staff orientation and training

Note: most root cause analyses indicate problems in multiple areas.

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4
Q

Which piece of legislation established a new set of standards for corporate responsibility?

A

Sarbanes-Oxley Act

Sarbanes-Oxley requires chief executive officers and chief financial officers to certify financial reports.

Unites States’ Patriot Act increased the abilities of federal officials to monitor communications and discover money-laundering operations.

Foreign Corrupt Practices Act changed the rules for international businesses, both by explicitly outlawing bribes to foreign officials and by standardizing accounting practices for American businesses that operate overseas.

Stark Law prohibits physicians from referring Medicare and Medicaid patients to healthcare providers with which the physician has a financial relationship.

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5
Q

According to the Federal Sentencing Guidelines, which of the following factors could increase the punishment of an organization?

A
  1. Obstruction of Justice
  2. Violation of a direct court order
  3. Prior history of violations
  4. Cooperation with or tolerance of criminal activity
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6
Q

When a hospital official notes that most errors are occurring at the “sharp end,” she means that…

A

they occur during the interaction between caregivers and patients.

The phrases “sharp-end” and “blunt end” are used by quality management professionals to describe areas of practice. The “sharp-end” is all of the operations that involve direct contact with the patient, client, or customer.

The “blunt end” is all of the actions that take place outside of the awareness of the patient, client, or customer.

Although patients are more likely to notice errors at the sharp end, there are significantly more errors committed at the blunt end.

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7
Q

The majority of fraud and abuse violations relate to irregularities in…

A

Billing

The two most common forms of billing fraud are unbundling and upcoding.

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8
Q

Which of the following words best describes the approach to punishment of the Federal Sentencing Guidelines?

A

case-specific

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9
Q

Which of the following groups may request information from the Healthcare Integrity and Protection Data Bank?

A
  1. State agencies
  2. Federal government agencies
  3. Health plans
  4. Healthcare practitioners
  5. Researchers - but are only allowed to obtain statistical data from the data bank
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10
Q

Research suggests that the largest proportion of adverse events attributable to negligence occur in the…

A

emergency room

Note: Standardization and comprehensive training can diminish, though not eliminate, the incidence of adverse events related to negligence.

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11
Q

According to the Title II of the Health Insurance Portability and Accountability Act, disclosure of protected health information related to which of the following actions require the patient’s express written authorization?

A

The state in which the treatment occurred requires the patient’s express written authorization. (Title II of HIPAA)

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12
Q

Which of the following groups is least likely to report errors?

A

Independent contractors

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13
Q

Why does the Healthcare Quality Improvement Act provide confidentiality and legal immunity for health care peer review processes?

A

To encourage participation by physicians

Without the protection, according to the AMA medical professionals would be reluctant to cooperate.

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14
Q

What type of subpoena calls for the delivery of certain documents to the court?

A

Subpoena duces tecum

Subpoena ad testificandum demands a specific person appear and give testimony

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15
Q

Which of the following is NOT included in an explanation of benefits?

A

Patient’s medical history

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16
Q

A healthcare facility’s income statement is an example of a….

A

Retrospective Audit

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17
Q

Hospitals that implement computerized provider order entry (CPOE) almost always see a decline in…

A

Medication errors

CPOE is a standard program for automating medical instructions, simplifying inventory, and decreasing delays in order completion.

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18
Q

In the Current Procedural Terminology code set, Category III codes are for…

A

emerging technology

Category I includes codes for evaluation and management.

Category II codes pertain to performance measurement.

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19
Q

Because of a doctor’s poor handwriting, a prescription must be reworked before it leaves the pharmacy. Which of the following is true?

A

The prescription should not count towards the pharmacy’s yield.

In lean service provision, only those processes that are completed without the necessity of reworking or repair are considered as a part of yield. The goal of lean service implementation is to improve yields by reducing errors and defects.

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20
Q

The legal doctrine that assigns responsibility to a doctor for the behavior of his or her employees is…

A

Respondeat superior

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21
Q

In general, how many steps should a failure modes and effects analysis (FMEA) proceed in each direction?

A

In general, FMEA should proceed with two steps in each direction: identification of errors or defects (failure modes) and consideration of the consequences (effects analysis).

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22
Q

Which piece of legislation mandates that companies with securities listed in the United States abide by generally accepted accounting practices?

A

Foreign Corrupt Practices Act

also outlaws the practice of bribing foreign officials

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23
Q

Which piece of legislation made qui tam lawsuits possible?

A

False Claims Act

The qui tam provision enables whistleblowing.

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24
Q

The unethical practice of billing for a more expensive service that is actually provided is known as….

A

DRG (diagnosis-related group) creep

DRG creep is believed to be one of the most pervasive ethical violations in healthcare

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25
Q

Which of the following would result in a healthcare provider receiving a new national provider identifier?

A

Nothing

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26
Q

Which of the following conditions must be met for a patient to no longer be deserving of service under the Emergency Medical Treatment and Active Labor Act (EMTALA)?

A

The patient must be alert

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27
Q

Which of the following is NOT a possible punishment for a violation of the Stark Law?

A

Incarceration

The Stark Law is civil law.

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28
Q

Research suggests that people make fewer errors when they….

A

work in a team

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29
Q

Which of the following groups reports information to the Healthcare Integrity and Protection Data Bank?

A

Federal Agencies

Also:

  1. State Agencies
  2. Health Plans
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30
Q

In program evaluation and review technique (PERT), the earliest point at which a successor event may follow a prerequisite event is called the…

A

Lag time

PERT is a methodology for reducing organizational waste.

Lead time is the interval within which a preceding event must be finished so that there will be sufficient time to complete the next steps in the process.

Critical path is the minimum duration of the project, assuming that all steps in the process must be completed.

Fast track is a strategy for accelerating processes by performing several activities at the same time.

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31
Q

Which of the following is NOT one of the prerequisites for the voluntary self-disclosure program administered by the Office of the Inspector General?

A

The disclosure must be on behalf of an individual rather than an entity.

Requirements of a voluntary self-disclosure program:

  1. Must be on behalf of an entity rather than an individual.
  2. Disclosure may not be motivated by an investigation or pending proceedings.
  3. Must describe the wrongdoing and the harm that may have been caused to federal programs.
  4. Disclosing party must not be the subject of a bankruptcy proceeding, before or after the self-disclosure.
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32
Q

Which of the following is NOT one of the categories of obligations outlined in the Code of Ethics for Healthcare Compliance Professionals issued by the Healthcare Compliance Association?

A

Obligation to the government

Three categories of obligations under the Code of Ethics for Healthcare Compliance Professionals:

  1. Obligations to the Public
  2. Obligations to the Employing Organization
  3. Obligations to the Profession
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33
Q

Before conducting a safety audit in an emergency department, an administrator first needs to obtain….

A

A written set of safety standards

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34
Q

Which of the following is NOT covered by the Stark Law?

A

Physician services

Designated Health Services (DHS) covered by the Stark Law:

  1. Clinical Laboratory Services
  2. Occupational Therapy Services
  3. Physical Therapy Services
  4. Radiology
  5. Radiation Therapy
  6. Prosthetics, Orthotics, and Prosthetic Devices
  7. Outpatient Prescription Drugs
  8. Home Health Services
  9. Hospital Services
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35
Q

The secretary of which federal agency oversees the Food and Drug Administration?

A

Department of Health and Human Services

36
Q

In most hospitals, the release of the information department is a component of the….

A

Health Information Management Services Department

37
Q

According to the Institute of Medicine, which of the following is NOT one of the domains of quality care?

A

Government regulation

The three domains of quality care are:

  1. Customization
  2. Safety
  3. Intervention consistent with the latest medical findings
38
Q

The practice of separating claims which should be billed together is known as…

A

Unbundling

39
Q

A hospital’s medication system is vast, and various elements of it fall within the purview of several different departments. One important step towards reducing errors in this system is to…

A

give a single person responsibility for overseeing the entire system.

40
Q

Which type of audits are generally recommended for healthcare compliance programs?

A

Concurrent audits

Problems are identified and resolved as they emerge

41
Q

Which piece of legislation applies to claims for service that were NOT provided as requested?

A

Civil Monetary Penalties Law

42
Q

In comprehensive error rate testing, the portion of paid and denied claims that are incorrectly handled is known as the….

A

Paid claims error rate

For the purpose of calculating the paid claims error rate, the Medicare administrative contractors should include all of the dollars processed after a decision has been made regarding the claim.

43
Q

Which case established that a corporate director may breach his or her fiduciary obligations by failing to faithfully institute a compliance and ethics program?

A

Caremark International Derivative Litigation (1996)

44
Q

Which of the following is NOT one of the criteria categories identified by the Clinical Laboratory Improvements Amendments (CLIA)?

A

Accuracy

Seven critical categories identified by CLIA:

  1. Knowledge
  2. Training and experience
  3. Reagents and materials preparation
  4. Characteristics of operational steps
  5. Calibration, quality control, and proficiency testing materials
  6. Test system troubleshooting and equipment maintenance
  7. Interpretation and judgment
45
Q

Which of the following pieces of information is available in the Healthcare Integrity and Protection Data Bank, but not the National Practitioner Data Bank?

A

Criminal Convictions

Also includes:

  • Licensing and Certification actions
  • Exclusions from federal and state healthcare programs
46
Q

What is the most common reason for a certificate of medical necessity to require recertification?

A

Resupply of oxygen

47
Q

Which of the following statements about individually identifiable health information (IIHI) is false?

A

Individually identifiable health information (IIHI) provides the patient’s name.

48
Q

Which of the following is responsible for the most privacy violations of the Health Insurance Portability and Accountability Act?

A

Physical theft of data is responsible for the most HIPAA privacy violations.

Data disclosed w/o the authorization of the patient is the second most common cause of HIPAA privacy violations.

49
Q

According to the Office of the Inspector General, which of the following would be the least helpful measure for improving outpatient services?

A

Describing the hospital’s post-submission testing process to a fiscal intermediary.

Per the OIG, the most helpful measures to improve outpatient services are:

  • A hospital should evaluate any potential bills for outpatient services within the applicable time period
  • A hospital should implement computer software to identify outpatient services that are not being billed separately from inpatient services
  • A hospital should establish a regular manual review of outpatient service claim billing
50
Q

Which of the following is NOT one of the patient rights enumerated in the Patient Self-Determination Act?

A

Patients have the right to select their medication.

The Patient Self-Determination Acts gives patients the right to:

  1. Refuse Treatment
  2. Assist in the decision-making process; and
  3. Make advance health directives
51
Q

According to the Federal Sentencing Guidelines, which of the following factors could decrease the punishment of an organization?

A
  1. Violations are self-reported
  2. Cooperation with investigation
  3. Active steps are taken to accept responsibility for violations
  4. Establishing and maintaining an effective compliance and ethics program
52
Q

Which groups report information to the National Practioner Data Bank?

A
  1. Peer Review organizations
  2. Hospitals
  3. Medical Malpractice payers
  4. Professional societies w/formal peer review
  5. HMOs, group practices, managed care organizations
  6. State health care licensing & certification authorities
53
Q

The illegal practice of billing for a more expensive category of service than was actually provided is….

A

DRG (diagnosis-related group) creep

54
Q

The unethical practice of coding at a higher level than is warranted by the documentation is called….

A

Upcoding

55
Q

A request, offer, or payment of money or other items of value in exchange for services is called a….

A

Kickback

56
Q

Which piece of legislation prohibits individuals from intentionally submitting a false or fraudulent claim?

A

The False Claims Act

57
Q

Which piece of legislation declared that individuals convicted of three crimes related to healthcare could no longer participate in federally funded healthcare programs?

A

The Balanced Budget Act of 1997

58
Q

Washington State Medical Association v. Regence Blueshield (2007)

A

The court declared that managed care organizations must use objective criteria when measuring physician performance and programs for measuring physician performance must be subject to appeal.

59
Q

Medical Association of Georgia v. BlueCross and BlueShield of Georgia (2000)

A

The court required managed care organizations to tell physicians in advance how much they will be paid.

60
Q

Rush Prudential v. Moran (2002)

A

The Supreme Court asserted that the Employee Retirement Income Security Act (ERISA) does not supersede state independent review provisions. In other words, patients who are denied insurance benefits by an HMO may have this decision reviewed by an independent physician.

61
Q

The National Practioner Data Bank includes the following information:

A
  1. Medical malpractice payments
  2. Loss of licensure
  3. Negative findings by a state certification authority
  4. Other adverse licensure actions
  5. Adverse clinical privileging actions
  6. Adverse professional society membership actions
  7. Negative actions by a peer review organization
  8. Negative actions by a private accreditation organization
62
Q

What is individually identifiable health information (IIHI)?

A

IIHI is created or received by a healthcare clearinghouse, healthcare provider, health plan, or employer.

It may be related to the physical or mental health or condition of an individual, the provision of healthcare to him or her, or the provision of payment for healthcare.

This information either directly identifies the individual or provides enough detail that there is a reasonable basis to believe that it could be used to identify the individual.

63
Q

Corporate Integrity Agreements (CIA) are negotiated primarily between the….

A

OIG and the health care entity

64
Q

Organizations receiving more than $5 million in Medicaid Funds must provide education on the False Claims Act in accordance with the ….

A

Deficit Reduction Act

65
Q

A hotline caller states the coding department was instructed to code based on LCD requirements regardless of medical record information. Which of the following should be the compliance professional’s FIRST action?

A

Design a review to find facts and circumstances related to the complaint

66
Q

A compliance professional identified an issue with medical necessity. The compliance professional should collaborate with the….

A

case manager

67
Q

When non-compliance is substantiated, disciplinary action should be administered….

A

in a consistent manner.

68
Q

In the development of the annual work plan, physician contract compliance was prioritized as a high-risk area. When the compliance professional followed with management, it appeared that the monitoring identified for this area was never put into place. Which of the following should be the compliance professional’s FIRST step?

A

Conduct a probe sample

69
Q

Which is the BEST question to include in an employee exit interview?

A

Did you ever observe anything that made you feel uncomfortable?

70
Q

A compliance professional is conducting a policy review. Which following procedure MUST be included in the policy for statistically valid sampling and extrapolation?

A

Financial error rate exceeds 5% with a refund to occur within 60 days

71
Q

Incentive programs based on employee performance may be tied to increases in…

A

patient satisfaction

72
Q

A preliminary investigation identified payments to physicians for medical directorships without written contracts. Which should be the compliance professional’s NEXT step?

A

Determine if Medicare payments were received

73
Q

An organization identifies a potential issue when reviewing personal services and management contracts. Which of the following should the compliance professional consider in analyzing the issue?

A

Anit-Kickback Safe Harbors

74
Q

In an investigation, the MOST important responsibility of the compliance professional is to….

A

set the scop and sample size related to investigations

75
Q

A compliance professional discovers non-compliance with regulation. Which should the compliance professional do FIRST?

A

Conduct a baseline audit

76
Q

A record retention policy must be based on….

A

applicable state laws

77
Q

Training is scheduled for employees to learn about cost reporting risks. This type of training is an example of…

A

focused training

78
Q

Which of the following is MOST relevant in evaluating the effectiveness of a compliance training program?

A
  1. Percent of target audience attended
  2. Whether the training is computer-based or classroom-based
  3. Whether training adequately addresses areas of concern
  4. The improvement shown in pre and post-training quizzes

Answer: 1, 3, and 4 only

79
Q

Qui tam actions enable any person to bring forth an action to the…

A

government, based upon original information.

80
Q

An individual’s understanding of the compliance aspects of their job can BEST be enhanced by including compliance in….

A

Annual Evaluations

81
Q

Under HIPAA, a covered entity is required to disclose protected health information when….

A

the Secretary of DHHS requests the information

82
Q

The annual OIG work plan is a document that outlines the OIG’s annual….

A

investigation ideas

83
Q

Which agency indicates a self-evaluation after the discovery of potentially fraudulent acts?

A

OIG

84
Q

Reporting systems should be….

A

publicized to all employees

85
Q

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

86
Q

A compliance professional conducts an investigation into allegations of physicians and nurses taking pictures of injuries and posting them on a social network. It is confirmed that two physicians and a nurse have engaged in this behavior. Which of the following is the compliance professional’s and HR director’s BEST action?

A

Review and adhere to the organization’s disciplinary policy

87
Q

Coinsurance and deductibles can be waived….

A

if there is proven financial hardship

CHC Exam (10 decks)

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