Compliance 101- Study Guide Exam
with Guaranteed Pass Solutions 2026-
2027 Updated.
Compliance Program - Answer following rules and regulations
Integrity Program - Answer values and doing the right thing
Current Compliance activities in many organization - Answer o Equal Employment
Opportunity Commission (EEOC)
o Employee Retirement Income Security Act (ERISA)
o Wage and Hour Rule
o Occupational Safety and health Administration (OSHA)
o Nuclear Regulatory Commission
o Joint Commission on Accreditation of Healthcare Organization (JCAHO)
o Research compliance
What is a Compliance Program? - Answer o Prevention, Detection, Collaboration, and
Enforcement
o System of policies and procedures developed to assure compliance with and conformity to all
applicable federal and state laws governing organization
o Ongoing process, part of fabric of organization, commitment to ethical way of conducting
business
Who needs compliance? Why? - Answer o Physicians practices
o Medicare
o Ambulance Services
o 3rd Party Billing
o Pharmaceutical Manufacturing
o Hospitals
o Laboratories
o DME
o Home Health
HHS Office of Inspector General (OIG) in conjunction with Justice Department is responsible for
enforcing the rules and regulations under
,-Medicare/Medicaid laws
outlined as part of the
- Social Security Act and administered by - Answer CMS
Government estimates on fraud - Answer 10% of total US health care expenditures, about
$100 billion annually
Justice Department - Answer Violent Crime - 1st Priority
Health care fraud - 2nd Priority
Benefits of Compliance Program - Answer - Safeguards organization legal responsibility to
abide by applicable laws and regulations
- Demonstrate to employee and community the organization's commitment to good corporate
conduct
- Identify and prevent criminal and unethical conduct
- Improve the quality of patient care
-Create a centralized source of information on heath care regulations
- Develop a methodology that encourages employees to report potential problems
- Develop procedures that allow the prompt, thorough investigation of alleged misconduct
- Initiate immediate and appropriate corrective action
- Reduce the organization remedies, such as program exclusion
Per OIG "Current CMS reimbursement principles provide that certain of the costs associated
with the creation of a voluntarily established compliance program may be allowable on certain
types of hospital's cost report. The allowable costs, of course must at a minimum, be reasonable
and related to patient care." However, government imposed compliance program, or corporate
integrity agreement, are not allowed
Why Compliance Programs are Essential - Answer Payback to fiscal intermediaries or carriers
may result in audited services
Probation and court imposed programs
Government designed programs
Exclusion from government program
Reduced threat of qui tam (whistle-blower) lawsuit
OIG Top 10 Reason to Implement a Compliance Program - Answer 1. Adopting a compliance
program concretely demonstrates to the community at large that a provider has a strong
commitment to honesty and responsible corporate citizenship.
2. Compliance programs reinforces employee' innate sense of right and wrong.
, 3. An effective compliance program helps a provider fulfill its legal duty to government and
private payors.
4. Compliance programs are cost effective.
5. A compliance program provides a more accurate view of employee and contractor behavior
relating to fraud and abuse.
6. The quality of care provided to patients is enhanced by an effective compliance program.
7. A compliance program provides procedures to promptly correct misconduct.
8. An effective compliance program may mitigate any sanction imposed by the government.
9. Voluntarily implementing a compliance program is preferable to waiting for the OIG to
impose a Corporate Integrity Agreement (CIA).
10. Effective corporate compliance programs may protect corporate directors from personal
liability.
Corporate Integrity Agreement(CIA) - Answer If provider does not have one in place, the OIG
will develop on that is enforceable through corporate integrity agreement. CIA has detailed
policy, training, audit, and reporting requirement that are typically in force for 5 years and
involved substantial oversight.
HIPAA act of 1996 - Answer makes it a criminal offense to submit claims based on incorrect
codes or medically unnecessary services and the government has the power to exclude the
organization from Medicare, Medicaid, and a long list of other government.
Balance Budget Act of 1997 - Answer has three strike rule - 3 strikes and you're out clause,
requiring permanent expulsion for healthcare organization found guilty of fraud a third time.
False Claim Act (FCA) - Answer empowers government to investigate and bring civil action in
fraud case. Implemented during Civil War to curb war time price gouging
also allow private citizen to bring civil actions against an organization in the name of United
States. This action provided significant incentive for the private citizen to come forward. This
action is better known as Qui Tam, whistle blower.
Qui Tam - (Qui tam pro domino rege quam pro se ipso in hac parte sequitur) - Answer "he
who brings the action for the king as well as for himself." Can receive up to 15-25% of
government's total reward if DOJ accepts the case and 25-30% if DOJ declines the case.
CIA - (Corporate Integrity Agreement) - Answer organization does not admit fault or liability,
but does submit itself to government corrective action plan. Government imposed CIA have
been onerous in the past and is expected to become more onerous in the future. CIA are usually
3-5 years, but can last as long as 8 years.
with Guaranteed Pass Solutions 2026-
2027 Updated.
Compliance Program - Answer following rules and regulations
Integrity Program - Answer values and doing the right thing
Current Compliance activities in many organization - Answer o Equal Employment
Opportunity Commission (EEOC)
o Employee Retirement Income Security Act (ERISA)
o Wage and Hour Rule
o Occupational Safety and health Administration (OSHA)
o Nuclear Regulatory Commission
o Joint Commission on Accreditation of Healthcare Organization (JCAHO)
o Research compliance
What is a Compliance Program? - Answer o Prevention, Detection, Collaboration, and
Enforcement
o System of policies and procedures developed to assure compliance with and conformity to all
applicable federal and state laws governing organization
o Ongoing process, part of fabric of organization, commitment to ethical way of conducting
business
Who needs compliance? Why? - Answer o Physicians practices
o Medicare
o Ambulance Services
o 3rd Party Billing
o Pharmaceutical Manufacturing
o Hospitals
o Laboratories
o DME
o Home Health
HHS Office of Inspector General (OIG) in conjunction with Justice Department is responsible for
enforcing the rules and regulations under
,-Medicare/Medicaid laws
outlined as part of the
- Social Security Act and administered by - Answer CMS
Government estimates on fraud - Answer 10% of total US health care expenditures, about
$100 billion annually
Justice Department - Answer Violent Crime - 1st Priority
Health care fraud - 2nd Priority
Benefits of Compliance Program - Answer - Safeguards organization legal responsibility to
abide by applicable laws and regulations
- Demonstrate to employee and community the organization's commitment to good corporate
conduct
- Identify and prevent criminal and unethical conduct
- Improve the quality of patient care
-Create a centralized source of information on heath care regulations
- Develop a methodology that encourages employees to report potential problems
- Develop procedures that allow the prompt, thorough investigation of alleged misconduct
- Initiate immediate and appropriate corrective action
- Reduce the organization remedies, such as program exclusion
Per OIG "Current CMS reimbursement principles provide that certain of the costs associated
with the creation of a voluntarily established compliance program may be allowable on certain
types of hospital's cost report. The allowable costs, of course must at a minimum, be reasonable
and related to patient care." However, government imposed compliance program, or corporate
integrity agreement, are not allowed
Why Compliance Programs are Essential - Answer Payback to fiscal intermediaries or carriers
may result in audited services
Probation and court imposed programs
Government designed programs
Exclusion from government program
Reduced threat of qui tam (whistle-blower) lawsuit
OIG Top 10 Reason to Implement a Compliance Program - Answer 1. Adopting a compliance
program concretely demonstrates to the community at large that a provider has a strong
commitment to honesty and responsible corporate citizenship.
2. Compliance programs reinforces employee' innate sense of right and wrong.
, 3. An effective compliance program helps a provider fulfill its legal duty to government and
private payors.
4. Compliance programs are cost effective.
5. A compliance program provides a more accurate view of employee and contractor behavior
relating to fraud and abuse.
6. The quality of care provided to patients is enhanced by an effective compliance program.
7. A compliance program provides procedures to promptly correct misconduct.
8. An effective compliance program may mitigate any sanction imposed by the government.
9. Voluntarily implementing a compliance program is preferable to waiting for the OIG to
impose a Corporate Integrity Agreement (CIA).
10. Effective corporate compliance programs may protect corporate directors from personal
liability.
Corporate Integrity Agreement(CIA) - Answer If provider does not have one in place, the OIG
will develop on that is enforceable through corporate integrity agreement. CIA has detailed
policy, training, audit, and reporting requirement that are typically in force for 5 years and
involved substantial oversight.
HIPAA act of 1996 - Answer makes it a criminal offense to submit claims based on incorrect
codes or medically unnecessary services and the government has the power to exclude the
organization from Medicare, Medicaid, and a long list of other government.
Balance Budget Act of 1997 - Answer has three strike rule - 3 strikes and you're out clause,
requiring permanent expulsion for healthcare organization found guilty of fraud a third time.
False Claim Act (FCA) - Answer empowers government to investigate and bring civil action in
fraud case. Implemented during Civil War to curb war time price gouging
also allow private citizen to bring civil actions against an organization in the name of United
States. This action provided significant incentive for the private citizen to come forward. This
action is better known as Qui Tam, whistle blower.
Qui Tam - (Qui tam pro domino rege quam pro se ipso in hac parte sequitur) - Answer "he
who brings the action for the king as well as for himself." Can receive up to 15-25% of
government's total reward if DOJ accepts the case and 25-30% if DOJ declines the case.
CIA - (Corporate Integrity Agreement) - Answer organization does not admit fault or liability,
but does submit itself to government corrective action plan. Government imposed CIA have
been onerous in the past and is expected to become more onerous in the future. CIA are usually
3-5 years, but can last as long as 8 years.
