Chapter 2 Flashcards

1
Q

The code of Conduct

A

-demonstrates the organization’s ethical attitude and its enterprise wide emphasis on compliance
-will need to be tailored to the organization’s culture, business and corporate identity
-provides a process for proper decision making
-managers are encouraged to refer to the code of conduct whenever possible, even including elements or standards into performance reviews

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2
Q

Who must agree and abide by the Code of Conduct

A

-everyone from the board to volunteers must receive, read, understand and agree
-CIA’s require all employees to attest on an annual basis

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3
Q

Code of Conduct: Content Checklist

A

-Reflects cultures and values
-written plainly - suggested 8th grade reading level
-translated into other languages as appropriate
-Mentions organizational policies without completely restating them
-Is consistent with company policies and procedures

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4
Q

Code of Conduct and Employees

A

-all must receive, read and understand
-training should be provided specific to the code
-should attest to it in writing annually
-must be enforced failing and consistently through appropriate discipline
-should understand that noncompliance will bring about discipline

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5
Q

Code of Conduct Purpose

A

-Represent culture of organization
-summarize specific guidelines to follow
-allow employees to know what’s required of them
-provide process for proper decision making
-confirm employees put standards into everyday practice
-elevate corporate performance in basic business relationships
-confirms the organization upholds and supports proper compliance conduct

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6
Q

Compliance Policies and Procedures

A

-are specific and address identified areas of risk
-should be integrated into existing policies
-Only thing worse that not having a policy is having a policy and not following it
-make sure they are realistic and measurable

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7
Q

OIG work plan

A

-released in the fall of each year
-highlights those areas the government will give close attention to in the coming months
-be sure to target those areas and address them in the policy and procedures

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8
Q

What areas do Compliance related policies and procedures exist for?

A

-Auditing and monitoring
-compliance record retention
-self-disclosure
-regular sanction checks
-specific areas of risk
-Non-retaliation
-Stark/anti-kickback
-HIPAA Privacy and Security
-others

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9
Q

Upcoding

A

-using a billing code that provides a higher reimbursement rate than the billing code that actually reflects the service furnished
-HIPAA added an additional civil monetary penalty to the OIG sanction authorities for upcoding violations

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10
Q

DRG Creep

A

practice of billing using a DGR code that provides a higher payment rate than the DRG code that accurately reflects the service furnished to the patient

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11
Q

Civil Monetary Penalties Law (CMPL)

A

regulations which apply to any claim for an item or service that was not provided as claimed or that was knowingly submitted as false and which provides guidelines for the levying of fines for such offences

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12
Q

Teaching physicians

A

-effective July 1996 and revised November 2002
-outlines documentation regulations for services provided by residents and teaching physicians

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13
Q

Non-retaliation policy

A

-should be developed and communicated
-if employees are afraid to bring issues forward a compliance program could not be effective

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14
Q

Government comes knocking

A

develop policies so that your staff knows what to do if presented with a subpoena, search warrant or if questioned by a government investigator
-cannot tell them what they must do but can tell them what their rights are

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15
Q

Anti-Kickback Statute

A

-prohibits any knowing and willful conduct involving the solicitation, receipt, offer, or payment of any kind of remuneration in return for referring an individual or for recommending or arranging the purchase, lease or ordering of an item or service that may be wholly or partially paid for under a federal health care program.
-is a criminal statute

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16
Q

Anti-Kickback Statue Penalties

A

-hefty fines
-imprisonment
-any reimbursement secured under an illegal referral may be considered a false claim

17
Q

Examples of Anti-kickback Violations

A

-offering office space at no charge or less than fair market value to physicians
-cut-rate support services such as dictation or secretarial services
-computer equipment provided at no charge by a pharmaceutical company

18
Q

Safe harbors

A

Explicit regulatory exceptions to otherwise legally prohibited conduct. Federal safe harbor regulations specify certain joint ventures and other arrangements concerning hospitals and/or physicians which do not violate Medicare fraud and abuse laws

19
Q

Stark Law

A

-Self-referral statute
-a physician or an immediate family member has a financial relationship with an entity that provides designated health services (DHS) that the physician may not make a referral for any DHS that is reimbursable by Medicare, and the entity that provides the services may not bill Medicare for the services provided as a result of the prohibited referral
-is a civil act and penalties are substantial

20
Q

Compliance Officers Duties

A

-implementation, administration day to day oversight of program
-reporting to the governing body
-revising program as appropriate
-develop, coordinate and participate in the education and training
-ensure independent contractors and agents are aware of the program requirements
-ensure background checks are done
-assist with auditing and monitoring activities
-independently investigating and acting on matters related to compliance

21
Q

Who is the focal point of the Compliance program

A

the compliance officer

22
Q

The Health Care Compliance Association’s three principles

A

-Obligation to the public-should embrace the spirit and the letter of the law
-Obligation to the employing organization
-obligation to the profession

23
Q

What different perspectives does the OIG believe will benefit the committee

A

-operations
-finance
-audit
-human resources
-utilization review
-social work
-discharge planning
-medicine
-coding and legal
-employees and managers of key operating units

24
Q

Compliance committee functions

A

-participating in the identification and prioritization of risk
-regularly reviewing and assessing compliance policies and procedures
-assisting with the development of standards of conduct and policies and procedures
-conducting an annual review of the Compliance Plan document
-determining the appropriate strategy to promote compliance
-developing a system to solicit, evaluate, and respond to complaints and problems

25
Q

What are the first and possibly most important lines of defense for a compliance program?

A

Education and training

26
Q

How does the OIG suggest training

A

2 separate types
-1 a general session on compliance for all employees
-2 coving more specific information for appropriate personnel

27
Q

General Compliance Training would at least include?

A

-elements of your compliance program
-your organization’s Code of Conduct
-The reporting system
-Individual accountability for reporting suspected non-compliance
-Non-retaliation policy
-who the compliance officer is
-explanation of fraud, waste and abuse

28
Q

How many educational hours does the OIG recommend annually for basic training?

A

There is no definite timeframe however 1-3 hours is required in many CIAs

29
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30
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31
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