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CHC exam Questions and Answers 2023

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CHC exam Questions and Answers 2023 Chapter 8 Federal Sentencing Guidelines (FSG) Ans- Guidelines and policy in this section apply to sentencing in federal criminal prosecution when the convicted defendant is an organization FSG- 4 factors that increase ultimate punishment of an organization Ans- 1.Involvement in or tolerance of criminal activity 2.Prior history of the organization 3.The violation of an order 4.The obstruction of justice FSG- The two factors that mitigate the ultimate punishment of an organization Ans- 1.The existence of an effective compliance and ethics program 2. Self-reporting,cooperation, or acceptance of responsibility FSG - The 4 general principles Ans- 1. The court orders the organization to remedy harm caused by the offense. 2.If the organization operated primary for a criminal purpose or primarily by criminal means the fine should divest it of all assets. 3. Fine based on seriousness and culpability (6 factors) 4. Probation is appropriate when needed to ensure another sanction is fully implemented or to ensure steps will be taken to reduce likelihood of future offense. FSG-High-level personnel of the organization Ans- Individuals who have substantial control over the organization or who have a substantial role in the making of policy or has substantial ownership interest FSG-Substantial authority personnel Ans- Individuals who within the scope of their authority exercises substantial measure of discretion in acting on behalf of an organization. High-level included in definition . Examples manager,can negotiate contracts or prices, supervisory authority. No of these examples is required, determined on a case by case basis. FSG-Condoned Ans- If individual knew of the offense and didn't take reasonable steps to prevent or terminate the offense. FSG- willfully ignorant of the offense Ans- If the individual did not investigate the possible occurrence of unlawful conduct despite knowledge of circumstances that would lead a reasonable person to investigate. FSG-Part B:Methods for remedying harm Ans- 1.Restitution order or probation requiring restitution. 2.Remedial order or community service when harm would not be otherwise remedied. FSG Restitution to identifiable victim Ans- Can be made in lump sum, partial payments at specifed intervals, in - kind payments or combination of each. FSG-in-kind payment Ans- 1. Return of property 2. Replacement of property 3. If the victim agrees services rendered to the victim or to a person organization other than the victim FSG - Remedial Orders Ans- RO as part of Probation can require organization to remedy harm and eliminate or reduce the risk the offense will cause future harm. If future harm can be reasonably estimated then court can require the organization to create a trust fund sufficient to address that expected harm. FSG-Community Service Ans- An organization can perform community service only by employing it's resources or paying it's employees or others to do so. FSG-Compliance and ethics program. 4 factors to consider in meeting requirements Ans- A). Applicable Government Regulation and Industry Practice B).Size of the organization C).Recurrence of similar misconduct FSG-Small Organization Ans- 200 employees FSG-Pervasiveness under subsection b. Ans- Case specific, depends on number and degree of responsibility, of individuals within substantial authority personnel who participated in,condoned, or were willfully ignorant of the offense. Obstruction does not apply to Ans- Individuals hiding from organization 5 most important federal fraud and abuse laws Ans- *False Claims Act (FCA) *Ant - kickback Statute (AKS) *Physician Self-referral *Law (Stark I II III ) *Exclusion Authorities *Civil Monetary Penalties Law (CMPL) Stark - designated health services (DHS) Ans- *labs *PT,OT,Outpatient Speech/Language Pathology *Radiology, some other imaging *Radiation therapy, supplies *DME *Parenteral enteral nutrients supplies *Prosthetic Orthotic supplies devices *Home Health services *Outpatient Rx drugs *Inpatient and Outpatient Hospital Services Stark - strict liability Ans- Proof of intent not required to prosecute Stark Ans- Prohibits physicians from referring patients to receive DHS payable by Medicare or Medicaid from entities with which the physician or immediate family member has a financial relationship unless an exception applies. Stark-penalties Ans- Fines and exclusion from federal healthcare programs. Stark-"Stand in shoes" Ans- DHS entity that owns or controls an entity to which a physician refers Medicare patient for DHS. =A direct compensation arrangements. Audit- "Retrospective Audit","Baseline Audit","Snap Shot Audit" Ans- Broad risk assessment of all areas you need to fix. Used to develop benchmarks. AuditConcurrent Audit: Ans- Audit as issues arise then go back at 3,6 or more months to follow up. DRA-Deficit Reduction Act Ans- Provides states with flexibility over Medicaid Programs . Can implement innovative ideas. DRA-6044 Ans- Allows state Medicaid plans to mirror commercial insurance packages through use of benchmark plans. DRA-6041 &6042 Ans- States can vary the premiums and cost sharing . No premiums are permitted for families with income above 100% and at/below 150% of FPL. Also requires payment of alternative premiums as a condition of eligibility and alternative cost sharing as a condition of receipt of the service or drug or cost sharing of non-emergency services in ER. Not to exceed 5% of family income fir the month or quarter period. DRA-LTC =Long Term Care Ans- LTC Partnership is a unique combination of private insurance and special access to Medicaid while still protecting assets. DRA-MFP=Money Follows the Person Ans- Section 6071 supports states in rebalancing LTC through 5 years if competitive grants that support targeted reforms to strengthen community-based infrastructure DRA- Transfer of Assets Ans- Sections include several provisions to discourage "Medicaid Planning". DRA- Documentation of Citizenship Ans- Section 6036 requires states to obtain proof of Citizenship and identity in order to receive Federal Financial Participation (FFP). DRA-Health Opportunity Accounts Ans- Section 6082 allows for 10 states to deliver Medicaid benefits through an Health Opportunity Account (HOA) in combo with high deductible health plans DRA- 3rd Party Ans- Section 6035 enhance state's ability to find and recover 3rd party liabilities primary to Medicaid DRA-MIP=Medicaid Integrity Program Ans- Section 6032 requires entities that receive or make payments of 5 mil annually to provide Federal False Claims Act education to employees. MIP was formed by section 6034 with more resources for CMS to use to fight Medicaid Fraud, Waste, & Abuse. DRA-HCBS (Home and Community-Based Services) Waiver Ans- States can amend their state plans to offer HCBS as a State Plan Optional Benefit (SPO) This allows states to offer most services now covered under the waiver except "other services ". New DRA option breaks eligibilty link between HCBS and institutional care. False Claims Act (FCA) 31 USC sections Ans- Enacted in 1863 due to concerns suppliers to Union Army were defrauding the Army. States any person who *knowingly* makes a false claim to gov is liable for treble the claim plus $5k-$10k (raised over the years) per false claim HCCA-"Compliance Program" Ans- A systematic process aimed at ensuring that the organization and it's employees ( & perhaps businesses partners ) comply with applicable laws regulations and standards. HCCA - 2 basic components of a compliance program Ans- 1. Structural 2. Substantive HCCA-"Structural Component" Ans- OIG 7 elements HCCA-"Substantive Component" Ans- Specific bodies of law such as Medicare, Medicaid, AKS,Stark,ERISA. FSG-COMPLIANCE Program def Ans- A program that has been reasonably desigbed, implemented, and enforces so that it generally will be effective in preventing and detecting criminal conduct. FSG-7 elements Ans- 1 . Compliance standards (P&P ect) 2. High Level Responsibility 3. Trustworthy indv 4 . Education 5 Monitoring 6. Enforcement 7.Response and Prevention HCCA- Evaluation and Measurement 2 dimensions Ans- 1 . EFFORT 2. OUTCOMES HCCA- effort Ans- Time money resources commitment HCCA-outcomes Ans- Impact efforts have had on level of compliance FCA - LIABILITY Ans- Knowingly submits,causes another to submit a false claim,or knowingly makes a false record or statement to get a false claim paid by government. Conspire to to violate FCA. Also see reverse FC section FCA - LIABILITY cont "Reverse false claim section " Ans- Act improperly to avoid having to pay government. FCA - DAMAGES and PENALTIES Ans- Fines of $5k- 10k (varies due to adjustments ) /claim plus treble government damages unless self-reported then under certain circumstances not less than double government damages FCA-Knowledge requirement Ans- 3729(b)(1) 1. Actually knowledge 2 . Deliberate ignorance of truth or falsity of information 3.Reckless disregard for of the truth or falsity of the information FCA-"claim" Ans- Demand for money or property made to Federal Government or contractor,grantee,or other recipient if the money is spent on the government's behalf and if Federal Government provides any of the money demanded or if the Federal Government will reimburse the contractor or grantee. *Doesn't apply to tax claims* FCA - qui tam provision Ans- Allows private persons to file suit for violations of FCA on behalf of the government. FCA-"relator" Ans- Person bringing qui Tam suit FCA - qui tam process Ans- Made under seal to US Attorney of the judicial district where filed and on the AG of US. Stays sealed for 60 days while feds investigate. Government then notifies relator that they will proceed "intervening" or decline. If declined relator can proceed. Relator must get fed approval for settlement. If government intervenes 15 - 25% to relator. If declined 25-30% for relator. HCCA - "code of conduct" Ans- Sets forth in general terms the organization's commitment to comply with the law. HCCA - 3 broad categories of policies and procedures Ans- i. CODE OF CONDUCT ii. OPERATION OF COMPLIANCE PROGRAM iii. Addressing organization's principal HCCA -P&P Ans- P&P Outcome : *audits reveal fewer errors *Successful testing of internal controls *Employees can express understanding of P&

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CHC exam Questions and Answers 2023
Chapter 8 Federal Sentencing Guidelines (FSG) Ans- Guidelines and policy in this section apply to
sentencing in federal criminal prosecution when the convicted defendant is an organization



FSG- 4 factors that increase ultimate punishment of an organization Ans- 1.Involvement in or tolerance
of criminal activity

2.Prior history of the organization

3.The violation of an order

4.The obstruction of justice



FSG- The two factors that mitigate the ultimate punishment of an organization Ans- 1.The existence of
an effective compliance and ethics program

2. Self-reporting,cooperation, or acceptance of responsibility



FSG - The 4 general principles Ans- 1. The court orders the organization to remedy harm caused by the
offense.

2.If the organization operated primary for a criminal purpose or primarily by criminal means the fine
should divest it of all assets.

3. Fine based on seriousness and culpability (6 factors)

4. Probation is appropriate when needed to ensure another sanction is fully implemented or to ensure
steps will be taken to reduce likelihood of future offense.



FSG-High-level personnel of the organization Ans- Individuals who have substantial control over the
organization or who have a substantial role in the making of policy or has substantial ownership interest



FSG-Substantial authority personnel Ans- Individuals who within the scope of their authority exercises
substantial measure of discretion in acting on behalf of an organization. High-level included in definition
. Examples manager,can negotiate contracts or prices, supervisory authority. No of these examples is
required, determined on a case by case basis.



FSG-Condoned Ans- If individual knew of the offense and didn't take reasonable steps to prevent or
terminate the offense.

, FSG- willfully ignorant of the offense Ans- If the individual did not investigate the possible occurrence of
unlawful conduct despite knowledge of circumstances that would lead a reasonable person to
investigate.



FSG-Part B:Methods for remedying harm Ans- 1.Restitution order or probation requiring restitution.

2.Remedial order or community service when harm would not be otherwise remedied.



FSG Restitution to identifiable victim Ans- Can be made in lump sum, partial payments at specifed
intervals, in - kind payments or combination of each.



FSG-in-kind payment Ans- 1. Return of property

2. Replacement of property

3. If the victim agrees services rendered to the victim or to a person organization other than the victim



FSG - Remedial Orders Ans- RO as part of Probation can require organization to remedy harm and
eliminate or reduce the risk the offense will cause future harm. If future harm can be reasonably
estimated then court can require the organization to create a trust fund sufficient to address that
expected harm.



FSG-Community Service Ans- An organization can perform community service only by employing it's
resources or paying it's employees or others to do so.



FSG-Compliance and ethics program. 4 factors to consider in meeting requirements Ans- A). Applicable
Government Regulation and Industry Practice

B).Size of the organization

C).Recurrence of similar misconduct



FSG-Small Organization Ans- <200 employees

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