Free CHC Exam Flashcards

It states organization-wide ethical values and behavioral expectations. Detailed policies and procedures translate those expectations into requirements and operational steps for particular risks.

A policy states the rule, responsibility, or expected outcome. A procedure specifies who performs the required steps, when they occur, and what evidence is retained.

Emerging laws, enforcement guidance, audit findings, incidents, new services, acquisitions, technology, or changed risk exposure should trigger review and documented revision through the organization's policy process.

They have different elements and protections. A Stark exception does not automatically resolve Anti-Kickback risk, and an Anti-Kickback safe harbor does not establish Stark compliance.

Use, request, or disclose only the PHI reasonably needed for the purpose. It generally does not apply to provider-to-provider treatment disclosures, disclosures to the individual, or authorized disclosures.

It must prohibit retribution for good-faith reporting or participation, identify reporting and escalation routes, and be supported by monitoring and consistent action when retaliation is suspected.

Written standards; leadership and oversight; training; effective communication and disclosure channels; incentives and consequences; risk assessment, auditing, and monitoring; and response to detected offenses with corrective action.

Staffing, expertise, technology, and budget should reflect the organization's size, services, geography, regulatory exposure, and risk profile—not a one-size-fits-all headcount.

Timely visibility into material risks, investigations, audit trends, corrective actions, resources, and program effectiveness so the board can exercise informed oversight and challenge management.

Provide sufficient authority, resources, direct access to the governing body, and an independent reporting route that prevents operational leaders from filtering or suppressing compliance concerns.

Its purpose, membership, authority, meeting cadence, decision rights, escalation duties, documentation, and accountability for supporting and evaluating the compliance program.

Clear ownership reduces gaps, duplication, and conflicts. It also identifies who advises, investigates, decides, implements, validates, and reports without compromising independence or privilege.

Map the program to its operations, payers, workforce, third parties, jurisdictions, and current industry risks while preserving organization-wide accountability for compliance.

Activity counts show work performed; effectiveness evidence shows whether risks were prevented, detected, corrected, and kept from recurring, using outcomes, trends, testing, and stakeholder feedback.

Assign an owner to assess applicability, revise policies and workflows, communicate and train affected groups, implement controls, and test whether the change works in practice.

It requires disclosure, review by an appropriate independent party, documented mitigation or recusal, and periodic updates when roles, relationships, or financial interests change.

Embed it in job descriptions, onboarding, performance evaluations, and exit interviews so expectations, observed concerns, and accountability are addressed across the employment lifecycle.

Check applicable exclusion and sanctions sources, verify possible matches with identifiers, document resolution, address confirmed exclusions, and investigate ownership, reputation, qualifications, and conflicts before engagement.

General training establishes baseline duties for broad audiences. Risk-specific training teaches affected roles how to recognize and control the particular risks they encounter.

Convert it into audience-specific decisions, responsibilities, examples, escalation points, and job aids without changing the rule's meaning or omitting important exceptions.

Civil FCA knowledge includes actual knowledge, deliberate ignorance, and reckless disregard. A compliance response should verify facts rather than assume every error is intentional fraud.

Use role-based scenarios, knowledge checks, observation, audit results, and follow-up testing. Completion records alone show participation, not whether behavior or decisions improved.

Document the learner, content, date, delivery method, instructor or source, completion, and assessment results so the organization can demonstrate coverage and follow up on gaps.

People know where to ask questions, report concerns without fear, receive timely feedback when appropriate, and see leaders respond consistently rather than rewarding silence.

Questions can prevent violations before they occur. A visible route for clarification complements reporting channels and helps compliance identify confusing policies or recurring risk areas.

The recurring observation of claim edits is monitoring. The defined retrospective review is auditing: an objective examination against criteria with documented scope, methodology, findings, and follow-up.

Prioritize auditable activities according to likelihood, impact, detectability, regulatory attention, prior findings, and available controls; document why resources address the highest risks.

It records risk owners, causes, controls, ratings, mitigation, deadlines, and status, enabling transparent prioritization and reassessment as evidence or operations change.

Do not promise absolute confidentiality. Explain that anonymity and confidentiality are protected within legal and practical limits and information is shared only as needed.

Assess immediate safety or ongoing harm, conflicts, evidence-preservation needs, mandatory deadlines, privilege considerations, credibility indicators, and the appropriate owner and urgency.

Track adverse actions, schedule follow-up with the reporter when feasible, review management decisions for consistency, preserve confidentiality, and escalate suspected retaliation promptly.

Qualified reviewers apply defined criteria and disclose conflicts; people responsible for the activity should not control the scope, evidence, conclusions, or reporting of findings.

Match the sample to the objective, population, known risk, data quality, and intended inference. A targeted probe can identify issues but cannot automatically support statistical extrapolation.

Patterns across time, locations, providers, codes, or controls can identify recurrence, outliers, improvement, deterioration, and where deeper review or resources are warranted.

Validate scope and findings, identify broader exposure, assign remediation, meet response obligations, inform governance, and incorporate lessons into risk assessment and future monitoring.

Not when tasks are merely marked complete. Closure requires evidence that actions were implemented, responsible owners accepted them, and follow-up testing shows the control is effective.

Comparable conduct should receive consistent treatment across seniority, revenue, professional status, or department, subject to documented differences in facts and applicable policy.

It should be timely, proportionate to the conduct and circumstances, consistent with policy and precedent, coordinated with appropriate functions, and documented.

Exempting influential people undermines accountability, weakens reporting culture, and signals that written standards are optional. Compliance expectations apply at every organizational level.

Stop impermissible participation, follow policy, assess affected services and claims, coordinate timely action, document decisions, and make any required payer or regulatory reports.

Triage immediate harm and preserve relevant evidence while restricting access only as necessary. Avoid premature conclusions, broad disclosures, or changes that could destroy information.

State the allegations, issues, period, entities, records, witnesses, investigator authority, reporting route, and known limitations; update the scope when evidence justifies expansion or narrowing.

When legal advice, privilege, government exposure, disclosure duties, litigation risk, or conflicts are material. Counsel's involvement does not automatically make every business fact privileged.

Use conflict-free investigators, test exculpatory and inculpatory evidence, document methods, protect information on a need-to-know basis, and give conclusions only the certainty the evidence supports.

Use qualified expertise when the issue requires specialized clinical, coding, valuation, privacy, technical, statistical, or regulatory judgment beyond the investigation team's competence.

Immediate controls may be necessary to stop ongoing harm, unsafe conduct, improper billing, evidence loss, or privacy exposure while preserving an objective inquiry into causes and scope.

It asks why the control system allowed the conduct—not merely who erred—so remediation can address incentives, process design, training, oversight, technology, and accountability.

Each action has an accountable owner, deadline, required evidence, risk-reduction purpose, escalation path, and effectiveness test tied to the investigation's root causes.

With counsel, match the conduct and legal exposure to the appropriate agency protocol; preserve deadlines, quantify supported facts, avoid unsupported conclusions, and coordinate repayment obligations.

Preserve records, follow lawful process, coordinate through designated counsel and leaders, provide accurate timely responses, avoid obstruction or speculation, and track commitments through closure.