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CHC exam questions and answers already passed Chapter 8 Federal Sentencing Guidelines (FSG) ✔✔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 ✔✔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 ✔✔1.The existence of an effective compliance and ethics program 2. Self-reporting,cooperation, or acceptance of responsibility FSG - The 4 general principles ✔✔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 ✔✔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 ✔✔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 ✔✔If individual knew of the offense and didn't take reasonable steps to prevent or terminate the offense. FSG- willfully ignorant of the offense ✔✔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 ✔✔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 ✔✔Can be made in lump sum, partial payments at specifed intervals, in - kind payments or combination of each. FSG-in-kind payment ✔✔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 ✔✔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 ✔✔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 ✔✔A). Applicable Government Regulation and Industry Practice B).Size of the organization C).Recurrence of similar misconduct FSG-Small Organization ✔✔<200 employees FSG-Pervasiveness under subsection b. ✔✔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 ✔✔Individuals hiding from organization 5 most important federal fraud and abuse laws ✔✔*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) ✔✔*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 ✔✔Proof of intent not required to prosecute Stark ✔✔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 ✔✔Fines and exclusion from federal healthcare programs. Stark-"Stand in shoes" ✔✔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" ✔✔Broad risk assessment of all areas you need to fix. Used to develop benchmarks. AuditConcurrent Audit: ✔✔Audit as issues arise then go back at 3,6 or more months to follow up. DRA-Deficit Reduction Act ✔✔Provides states with flexibility over Medicaid Programs . Can implement innovative ideas. DRA-6044 ✔✔Allows state Medicaid plans to mirror commercial insurance packages through use of benchmark plans. DRA-6041 &6042 ✔✔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 ✔✔LTC Partnership is a unique combination of private insurance and special access to Medicaid while still protecting assets. DRA-MFP=Money Follows the Person ✔✔Section 6071 supports states in rebalancing LTC through 5 years if competitive grants that support targeted reforms to strengthen communitybased infrastructure DRA- Transfer of Assets ✔✔Sections 6011-6016 include several provisions to discourage "Medicaid Planning". DRA- Documentation of Citizenship ✔✔Section 6036 requires states to obtain proof of Citizenship and identity in order to receive Federal Financial Participation (FFP). DRA-Health Opportunity Accounts ✔✔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 ✔✔Section 6035 enhance state's ability to find and recover 3rd party liabilities primary to Medicaid DRA-MIP=Medicaid Integrity Program ✔✔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 ✔✔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 3729-3733 ✔✔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" ✔✔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 ✔✔1. Structural 2. Substantive HCCA-"Structural Component" ✔✔OIG 7 elements HCCA-"Substantive Component" ✔✔Specific bodies of law such as Medicare, Medicaid, AKS,Stark,ERISA. FSG-COMPLIANCE Program def ✔✔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 ✔✔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 ✔✔1 . EFFORT 2. OUTCOMES HCCA- effort ✔✔Time money resources commitment HCCA-outcomes ✔✔Impact efforts have had on level of compliance FCA - LIABILITY ✔✔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 " ✔✔Act improperly to avoid having to pay government. FCA - DAMAGES and PENALTIES ✔✔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 ✔✔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" ✔✔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 ✔✔Allows private persons to file suit for violations of FCA on behalf of the government. FCA-"relator" ✔✔Person bringing qui Tam suit FCA - qui tam process ✔✔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" ✔✔Sets forth in general terms the organization's commitment to comply with the law. HCCA - 3 broad categories of policies and procedures ✔✔i. CODE OF CONDUCT ii. OPERATION OF COMPLIANCE PROGRAM iii. Addressing organization's principal HCCA -P&P ✔✔P&P Outcome : *audits reveal fewer errors *Successful testing of internal controls *Employees can express understanding of P&P HCCA -Ongoing Education and Training ✔✔Goals: *Promote understanding of compliance program, *Employees understand their role in compliance process *Demonstrate organizational comitment to compliance efforts *Communicate industry standards HCCA -Education : "Structural vs substantive ✔✔1. Structural, how compliance program operates 2. Substantive, specific laws and regulations that directly impact organization "ERISA" ✔✔Employment Retirement Income Security Act of 1974 ERISA-amendnents ✔✔COBRA ,HIPAA,Mental Health Parity Act,Newborn and Mother's Health Protection Act,Womens Health and Cancer Right Act ERISA - OVERVIEW ✔✔Federal Law that sets minimum standards for retirement and health benefit plans in private industry. ERISA - "employee welfare benefit plan" ✔✔Medical surgical,or hospital care benefits or benefits in the event if sickness,accident disability, death,or unemployment or vacation benefits. (Not pension ) ERISA -Fiduciary Duties ✔✔1.The assets of an employee welfare benefit plan must be held in trust by one or more trustee 2.Trustee must discharge duties solely in the interest of the plans participants and beneficiaries 3. Must be maintained and established pursuant to a written instrument which names one or more fiduciaries who have authority and control of plan operations 4 . fiduciaries must diversify the the investments and not engage in non-exempt transactions. 5. Fiduciaries must act prudently and can be held liable for a breach of duty GINA-"Genetic Information ,Nondiscrimination Act of 2008" ✔✔GINA-Protects against Genetic discrimination re employment and health insurance GINA- 2 PARTS ✔✔2 Parts 1. Title I.prevents discrimination regarding health insurance Title 2. prevents discrimination regarding employment GINA-TITLE I. ✔✔Title 1. Makes it illegal to require or use Genetic info to determine eligibility or coverage • GINA-TITLE II. ✔✔Title 2. illegal Foe employer to use genetic into for hiring Promotion or other teams of employment GINA-scope ✔✔GINA covers genetic information of an individual and the genetic information of family members (for example, in determining family health history of disease). GINA does not cover an individual's manifested disease or condition--a condition from which an individual is experiencing symptoms, being treated for, or that has been diagnosed. GINA-Title I. Scope of Protection ✔✔However, a health insurer may request that an individual provide genetic information if coverage of a particular claim may be appropriate only if there is a known genetic risk. AKS-ANTI-KICKBACK laws ✔✔the Anti-Kickback Statute as part of the Social Security Amendments AKS- role of intent ✔✔PPACA made AKS strick liability AKS - FCA relationship ✔✔The Patient Protection and Affordable Care Act of 2010 expanded the liability of the False Claims Act to now definitively include Anti-Kickback claims as grounds for violation. Prior to the healthcare reform, it was unclear whether or not Anti-Kickback claims constituted a violation of the False Claims Act. SOX- "Sarbaynes-Oxley Act of 2002. ✔✔mandated a number of reforms to enhance corporate responsibility, enhance financial disclosures and combat corporate and accounting fraud, and created the "Public Company Accounting Oversight Board," also known as the PCAOB, to oversee the activities of the auditing profession. SOX-CORP Responsibility ✔✔SOX Section 302 - Corporate Responsibility for Financial Reports a) CEO and CFO must review all financial reports. b) Financial report does not contain any misrepresentations. c) Information in the financial report is "fairly presented". d) CEO and CFO are responsible for the internal accounting controls. e) CEO and CFO must report any deficiencies in internal accounting controls, or any fraud involving the management of the audit committee. f) CEO and CFO must indicate any material changes in internal accounting controls. SOX- Internal Controls ✔✔SOX Section 404: Management Assessment of Internal Controls All annual financial reports must include an Internal Control Report stating that management is responsible for an "adequate" internal control structure, and an assessment by management of the effectiveness of the control structure. Any shortcomings in these controls must also be reported. In addition, registered external auditors must attest to the accuracy of the company management�s assertion that internal acc PPACA -Coverage ✔✔*Can't deny coverage to children under 19 due to preexisting condition *Can stay on parents coverage until 26 *Insurance can't rescind coverage due to honest mistake on application. Must provide 30 day notice prior to cancelation *Right to appeal denial through internal or external appeal. Insurer must provide info on appeal and State Consumer Assistance Progrm PPACA -Cost ✔✔*SOX Section 404: Management Assessment of Internal Controls All annual financial reports must include an Internal Control Report stating that management is responsible for an "adequate" internal control structure, and an assessment by management of the effectiveness of the control structure. Any shortcomings in these controls must also be reported. In addition, registered external auditors must attest to the accuracy of the company management�s assertion that internal acc PPACA -Care ✔✔Care Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment. Protects Your Choice of Doctors: Choose the primary care doctor you want from your plan's network. Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan's network. MHPAEA-"Mental Health Parity and Addiction Equity Act" ✔✔The Mental Health Parity Act of 1996 (MHPA) provided that large group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical/surgical benefits. MIPPA-"Medicare Improvements for Patients and Providers 2008 ✔✔Strengthens part D requirements, protection for beneficiaries, new marketing restrictions [Show More]

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