HCCA - CHC EXAM STUDY QUESTIONS
WITH 100% CORRECT ANSWERS
(EXPERT-GRADED A+)
1. Deficit Reduction Act of 2005 - ANSWER Requires that organizations
receiving more than $5 million in Medicaid funds must provide education on
the False Claims Act.
2. Corporate Integrity Agreement (CIA) - ANSWER A compliance program
imposed by the government, which involves substantial government
oversight and outside expert involvement in the organization's compliance
activities and is generally required as a condition of settling a fraud and
abuse investigation. Negotiated primarily between the OIG and the health
care entity.
3. HIPAA - ANSWER Comprehensive legislation that ensures access to health
coverage for those who change jobs or are temporarily out of work. It also
provides the mechanism for funding the DOJ and FBI for Medicare fraud
investigations.
4. Sherman Antitrust Act - ANSWER Prohibits conspiracies in restraint of
trade that affects interstate commerce. Physicians usually use this to file
lawsuits against hospitals for denial or removal of admitting privileges.
5. OCR - ANSWER A component of the Department of HHS that teaches
healthcare workers about civil rights, health information privacy, and patient
safety confidentiality laws.
,6. Retrospective Audit - ANSWER Audit completed after payment has been
received from a carrier. MCOs review claims that have been paid to a
physician practice over a set period of time to determine whether there has
been overpayment of claims.
7. AMA Model Managed Care Contract Sec. 3.10(d) - ANSWER Provides
that all payments to physicians and physician groups/networks will be final
unless adjustments are requested in writing by the MCO within 180 days
after receipt.
8. Medical Administrative Contracter (MAC) - ANSWER A private healthcare
insurer that has been awarded a geographic jurisdiction to process Medicare
Part A and B medical claims or DME claims for Medicare fee-for-services
beneficiaries. They also audit institutional provider cost reports,
redetermination request (1st stage of appeals process) and respond to
provider inquiries.
9. Medicare Prescription Drug Improvement and Modernization Act (MMS) of
2003 - ANSWER Directed CMS to replace Part A Fiscal Intemediaries and
Part B carriers with MACs.
10.Fraudulent Billing - ANSWER Willful and is undertaken with the intent to
receive payment for services not legitimately rendered.
11.Corporate Integrity Agreement (CIA) - ANSWER A compliance program
imposed by the government, which involves substantial government
oversight and outside expert involvement in the organization's compliance
activities and is generally required as a condition of settling a fraud and
abuse investigation. Negotiated primarily between the OIG and the health
care entity.
, 12.Seven Elements of a Compliance Program - ANSWER 1. Standards of
Conduct
2. Oversight & Resources
3. Education & Training
4. Auditing and Monitoring
5. Consistent and appropriate discipline
6. Reporting Processes
7. Response and Prevention of Problems
13.LEIE (List of Excluded Individuals) - ANSWER A list of individuals and
organizations that are excluded from participating/billing the federal
healthcare program (i.e. Medicare). This list is updated monthly and is the
responsibility of the organization to check their list of physicians,
employees, etc. against this to prevent a violation of the False Claims Act.
14.Medicare Cost Report - ANSWER A report that contains provider
information such as facility characteristics, utilization data, cost and charges
by the cost center. If administrator's or business associate pay appears on
this that is excluded from the LEIE, it may be liable as a FCA.
15.5 to 50 Years - ANSWER Mandatory Exclusion (felony) length
16.Up to 5 Years - ANSWER Permissive exclusion (misdemeanor) length
17.State Medicaid Exclusion List - ANSWER State Version of LEIE, also
monitored monthly
18.False Claims Act - ANSWER Prohibits anyone from knowingly submitting
or causing to be submitted a false or fraudulent claim to the government.
WITH 100% CORRECT ANSWERS
(EXPERT-GRADED A+)
1. Deficit Reduction Act of 2005 - ANSWER Requires that organizations
receiving more than $5 million in Medicaid funds must provide education on
the False Claims Act.
2. Corporate Integrity Agreement (CIA) - ANSWER A compliance program
imposed by the government, which involves substantial government
oversight and outside expert involvement in the organization's compliance
activities and is generally required as a condition of settling a fraud and
abuse investigation. Negotiated primarily between the OIG and the health
care entity.
3. HIPAA - ANSWER Comprehensive legislation that ensures access to health
coverage for those who change jobs or are temporarily out of work. It also
provides the mechanism for funding the DOJ and FBI for Medicare fraud
investigations.
4. Sherman Antitrust Act - ANSWER Prohibits conspiracies in restraint of
trade that affects interstate commerce. Physicians usually use this to file
lawsuits against hospitals for denial or removal of admitting privileges.
5. OCR - ANSWER A component of the Department of HHS that teaches
healthcare workers about civil rights, health information privacy, and patient
safety confidentiality laws.
,6. Retrospective Audit - ANSWER Audit completed after payment has been
received from a carrier. MCOs review claims that have been paid to a
physician practice over a set period of time to determine whether there has
been overpayment of claims.
7. AMA Model Managed Care Contract Sec. 3.10(d) - ANSWER Provides
that all payments to physicians and physician groups/networks will be final
unless adjustments are requested in writing by the MCO within 180 days
after receipt.
8. Medical Administrative Contracter (MAC) - ANSWER A private healthcare
insurer that has been awarded a geographic jurisdiction to process Medicare
Part A and B medical claims or DME claims for Medicare fee-for-services
beneficiaries. They also audit institutional provider cost reports,
redetermination request (1st stage of appeals process) and respond to
provider inquiries.
9. Medicare Prescription Drug Improvement and Modernization Act (MMS) of
2003 - ANSWER Directed CMS to replace Part A Fiscal Intemediaries and
Part B carriers with MACs.
10.Fraudulent Billing - ANSWER Willful and is undertaken with the intent to
receive payment for services not legitimately rendered.
11.Corporate Integrity Agreement (CIA) - ANSWER A compliance program
imposed by the government, which involves substantial government
oversight and outside expert involvement in the organization's compliance
activities and is generally required as a condition of settling a fraud and
abuse investigation. Negotiated primarily between the OIG and the health
care entity.
, 12.Seven Elements of a Compliance Program - ANSWER 1. Standards of
Conduct
2. Oversight & Resources
3. Education & Training
4. Auditing and Monitoring
5. Consistent and appropriate discipline
6. Reporting Processes
7. Response and Prevention of Problems
13.LEIE (List of Excluded Individuals) - ANSWER A list of individuals and
organizations that are excluded from participating/billing the federal
healthcare program (i.e. Medicare). This list is updated monthly and is the
responsibility of the organization to check their list of physicians,
employees, etc. against this to prevent a violation of the False Claims Act.
14.Medicare Cost Report - ANSWER A report that contains provider
information such as facility characteristics, utilization data, cost and charges
by the cost center. If administrator's or business associate pay appears on
this that is excluded from the LEIE, it may be liable as a FCA.
15.5 to 50 Years - ANSWER Mandatory Exclusion (felony) length
16.Up to 5 Years - ANSWER Permissive exclusion (misdemeanor) length
17.State Medicaid Exclusion List - ANSWER State Version of LEIE, also
monitored monthly
18.False Claims Act - ANSWER Prohibits anyone from knowingly submitting
or causing to be submitted a false or fraudulent claim to the government.
