Compliance 101 -Chapter 1 Test
Questions and Answers 2026 Updated.
Who is responsible for enforcing compliance? - Answer The HHS Office of the Inspector
General (OIG) in conjunction with the Justice Department is responsible for enforcing the rules
and regulations under the Medicare and Medicaid laws outlined by the Social Security Act and
administered by the Centers for Medicare and Medicaid Services (CMS)
Benefits of a Compliance Program - Answer 1. safeguards the organization's legal
responsibility to abide by the applicable laws and regulations
2. Demonstrates to employees and the community the organizations commitment to good
corporate conduct
3. Improve Patient Care
4.Create a centralized source of information on heath care regulations
5. Develop a mechanism for reporting
6. Develop procedures that allow the prompt, thorough investigations of alleged misconduct
7. Initiate immediate and appropriate corrective action
8.Reduce the organization's exposure to civil damages and penalties, criminal sanctions, and
administrative remedies, such as program exclusion.
9. Cost of not having a compliance program much more substantial
OIG reasons to Implement a Compliance Program - Answer 1. Adopting a compliance
program demonstrates to the community that a provider has a strong commitment to honesty
and responsible corporate citizenship
2. Compliance programs reinforce employees innate sense of right and wrong
3. Helps provider fulfill its legal duty to government and private payors (ensures claims are
accurate and truthful)
4. Cost-effective in comparison to the disruption and defense of defending against a fraud
investigation
5. Provides ongoing training for employees and contractors, monitors their understanding and
compliance with program rules, and provides mechanisms of discipline for those who violate
the code of conduct.
6. Quality of Care is enhanced.
7. Provides established procedures for promptly and efficiently responding to problems that
may arise. Through early detection and reporting, a company can minimize the loss to the
government from false claims and reduce the providers exposure to civil damages, penalties,
and criminal and administrative sanctions.
8. An effective compliance program can mitigate any sanction imposed by the government.
9. Voluntary implementation is better than an enforcement agency mandating a compliance
agreement
, 10. Protect corporate directors from personal liability
Penalties and fines resulting from non-compliance - Answer 1. HIPAA - makes it a criminal
offense to submit false claims based on incorrect codes or provide medically unnecessary
services, and provider can be excluded from Medicare
2. Balanced Budget Act of 1997 - has a three strikes and your out clause requiring permanent
expulsion for any health care organization found guilty of fraud a third time
3. False Claims Act - impowers the government investigate and bring civil action in fraud causes.
This creates an increased threat of qui tam (whistleblower) lawsuits.
4. Increased culpability score
Name the four aggravating factors and four mitigating factors to a "culpability score". - Answer
For Federal Sentencing Guidelines, a culpability score gives guidance for assessing fines through
detailed methods of calculation
Four aggravating factors:
- If an upper-level employee has participated in, condoned, or was willfully ignorant of the
offense
- If the violation was a repeat offense
- If the government was hindered during its investigation
- If awareness of and tolerance of the violation were pervasive
Four Mitigating Factors:
- If the organization had an effective compliance organization
- If the organization reported the violation promptly
- If the organization cooperated with the government investigators
- If the organization accepted responsibility for the violation
Ten Obstacles to Effective Compliance Implementation - Answer 1. No commitment and buy-
in from Board and Management
2. Lack of Resources
3. Dual roles for compliance professional
4. Unclear laws and regulations
5. Lack of education and training
6. Resistance to change
7. Communication problems
8. Fear of retaliation/retribution
Questions and Answers 2026 Updated.
Who is responsible for enforcing compliance? - Answer The HHS Office of the Inspector
General (OIG) in conjunction with the Justice Department is responsible for enforcing the rules
and regulations under the Medicare and Medicaid laws outlined by the Social Security Act and
administered by the Centers for Medicare and Medicaid Services (CMS)
Benefits of a Compliance Program - Answer 1. safeguards the organization's legal
responsibility to abide by the applicable laws and regulations
2. Demonstrates to employees and the community the organizations commitment to good
corporate conduct
3. Improve Patient Care
4.Create a centralized source of information on heath care regulations
5. Develop a mechanism for reporting
6. Develop procedures that allow the prompt, thorough investigations of alleged misconduct
7. Initiate immediate and appropriate corrective action
8.Reduce the organization's exposure to civil damages and penalties, criminal sanctions, and
administrative remedies, such as program exclusion.
9. Cost of not having a compliance program much more substantial
OIG reasons to Implement a Compliance Program - Answer 1. Adopting a compliance
program demonstrates to the community that a provider has a strong commitment to honesty
and responsible corporate citizenship
2. Compliance programs reinforce employees innate sense of right and wrong
3. Helps provider fulfill its legal duty to government and private payors (ensures claims are
accurate and truthful)
4. Cost-effective in comparison to the disruption and defense of defending against a fraud
investigation
5. Provides ongoing training for employees and contractors, monitors their understanding and
compliance with program rules, and provides mechanisms of discipline for those who violate
the code of conduct.
6. Quality of Care is enhanced.
7. Provides established procedures for promptly and efficiently responding to problems that
may arise. Through early detection and reporting, a company can minimize the loss to the
government from false claims and reduce the providers exposure to civil damages, penalties,
and criminal and administrative sanctions.
8. An effective compliance program can mitigate any sanction imposed by the government.
9. Voluntary implementation is better than an enforcement agency mandating a compliance
agreement
, 10. Protect corporate directors from personal liability
Penalties and fines resulting from non-compliance - Answer 1. HIPAA - makes it a criminal
offense to submit false claims based on incorrect codes or provide medically unnecessary
services, and provider can be excluded from Medicare
2. Balanced Budget Act of 1997 - has a three strikes and your out clause requiring permanent
expulsion for any health care organization found guilty of fraud a third time
3. False Claims Act - impowers the government investigate and bring civil action in fraud causes.
This creates an increased threat of qui tam (whistleblower) lawsuits.
4. Increased culpability score
Name the four aggravating factors and four mitigating factors to a "culpability score". - Answer
For Federal Sentencing Guidelines, a culpability score gives guidance for assessing fines through
detailed methods of calculation
Four aggravating factors:
- If an upper-level employee has participated in, condoned, or was willfully ignorant of the
offense
- If the violation was a repeat offense
- If the government was hindered during its investigation
- If awareness of and tolerance of the violation were pervasive
Four Mitigating Factors:
- If the organization had an effective compliance organization
- If the organization reported the violation promptly
- If the organization cooperated with the government investigators
- If the organization accepted responsibility for the violation
Ten Obstacles to Effective Compliance Implementation - Answer 1. No commitment and buy-
in from Board and Management
2. Lack of Resources
3. Dual roles for compliance professional
4. Unclear laws and regulations
5. Lack of education and training
6. Resistance to change
7. Communication problems
8. Fear of retaliation/retribution
