Medicare Part A & B Appeals Process: Key Practice Test Insights

CHC Practice Test Questions and Answers 100% Pass At which level of the Medicare Part A or B appeals process is the appeal reconsidered by a qualified independent contractor? a. first level appeal b. second level appeal c. third level appeal d. fourth level appeal ✔✔ b. second level appeal There are five levels of appeal. First level entails a redetermination of claim; second level involves reconsideration by a qualified independent contractor; third level includes a hearing overseen by admin law judge; fourth level is a review of Medicare Review Council; and fifth level is a judicial review in federal court. If an at-risk patient is left unattended and has an adverse response to medication, this is known as: a. sentinel event b. initiator

c. latent outcome d. slip ✔✔ a. sentinel event Sentinel event is an adverse occurrence that is not in the normal progression of a patient's illness. In this scenario, an adverse drug event is considered a sentinel event. AND whenever a sentinel events is confirmed, the facility should perform a Root Cause Analysis (RCA). A Latent Outcome - less apparent failures of organization or design that contributed to the error/patient harm. A Slip - can be a fall or an everyday risk at hospitals. A behavioral health specialist notices a particularly high number of restraint deaths at a facility. An analysis of the root causes of these events is most likely to indicate problems with: a. Equipment b. Staff orientation and training c. Staffing levels d. Alarm systems ✔✔ b. Staff orientation and training

Equipment, staffing levels, and alarm system can also be culpable in restraint deaths, but problems with orientation and training are much more likely. Which piece of legislation established a new set of standards for corporate responsibility? a. sarbanes-oxley act b. united states patriot act c. foreign corrupt practices act d. stark law ✔✔ a. sarbanes-oxley act Sarbanes-oxley act was passed after a series of high-profile financial scandals in early 2000s to protect shareholders, improving corporate governance and accountability setting new set of standards for corporate responsibility. According to the Federal Sentencing Guidelines, which of the following factors could increase the punishment of an organization? a. obstruction of justice b. violation of direct court order c. prior history of violations d. all of the above ✔✔ d. all of the above

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These are aggravating factors that increase the culpability score under the FSG. See FSG chapter 8-C2.5 https://guidelines.ussc.gov/gl/%C2%A78C2.5 When a hospital official notes that most errors are occurring at the "sharp end" she means that: a. they involve surgical tools or knives b. they occur in clusters c. they occur during the interactions between caregivers and patients d. they are most likely to occur during busy periods ✔✔ c. they occur during the interactions between caregivers and patients. The "sharp end" and "blunt end" are used by quality management professionals to describe areas of practice. "Sharp end" is all of the operations that involve direct contact with patient/client/customer. "Blunt end" is all actions that take place outside awareness of patient/client/customer. The majority of fraud and abuse violations relate to irregularities in: a. treatment b. diagnosis

c. billing d. scheduling ✔✔ c. billing Which of the following words best describe the approach to punishment of the Federal Sentencing Guidelines: a. case-specific b. draconian c. consistent d. remedial ✔✔ a. case-specific FSG takes numerous factors into account when determining punishment. The range of penalties that may be applied to a given violation is broad, and organizations may affect the severity of their punishment with their actions subsequent to the violation Which of the following groups may request information from the Healthcare Integrity and Protection Data Bank? a. professional societies with formal peer review b. quality improvements organizations c. plaintiff's attorneys

d. state agencies ✔✔ d. state agencies Other groups may include federal government, health plans, healthcare practitioners. Researchers are only allowed to obtain statistical data form the data bank. Research suggests that the largest proportions of adverse events attributable to negligence occur in the: a. post-trauma unit b. surgery unit c. maternity unit d. emergency unit ✔✔ d. emergency unit According to title II of HIPAA, disclosure of Protected Health Information related to which of the following actions requires the patient's express written authorization? a. state in which the treatment occur b. health care operations c. treatment d. payment ✔✔ a. state in which the treatment occur

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A covered entity may disclose PHI for TPO (treatment, payment, and healthcare operations) Which of the following groups is least likely to report errors: a. primary care physicians b. support staff c. independent contractors d. nurses ✔✔ c. independent contractors Why does Healthcare Quality Improvement Act provide confidentiality and legal immunity for health care peer review processes? a. to prevent malpractice suits b. to discourage complaints by patients c. to encourage participation by physicians d. to maintain a sterile work environment ✔✔ c. to encourage participation by physicians The Healthcare Quality Improvement Act provides confidentiality and legal immunity for healthcare Peer Review process to encourage participation by physicians. Which type of subpoena calls for the delivery of certain documents to the court?

a. subpoena habeas corpus b. subpoena ad testificandum c. subpoena add infinitum d. subpoena duces tectum ✔✔ d. subpoena duces tectum "subpoena ad testificandum" - means the court demands specific person appear and give testimony. The other options are not legal terms. Which of the following is generally NOT included in an Explanation of Benefits (EOB): a. date of service b. insurance code for service c. doctor's fee d. patient's medical history ✔✔ d. patient's medical history EOB only explains the elements of the medical treatment that are covered by health insurance policy

A healthcare facility's income statement is an example of: a. baseline audit b. retrospective audit c. concurrent audit d. snapshot audit ✔✔ b. retrospective audit Concurrent audit is real-time evaluations of records/policies. Snapshot audit is a comprehensive picture of the organization at a particular time. Baseline audit is also a comprehensive evaluation but undertaken for establishing benchmarks against which future performance may be compared. Hospitals that implement Computerized Provider Order Entry (CPOE) almost always see a decline in: a. medication errors b. diagnostic errors c. adverse events d. latent errors ✔✔ a. medication errors

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CPOE programs diminish error related to faulty transcript or unclear handwriting, and simplify inventory and decrease delays in order completion. In the Current Procedural Terminology (CPT) code set, Category II codes are for: a. emerging technology b. evaluation & management c. performance measurement d. medicine ✔✔ c. performance measurement CPT category I: evaluation & management. CPT category II: performance measurement. CPT category III: emerging technology. Because of a doctor's poor handwriting, a prescription must be reworked before it leaves the pharmacy. Which of the following is true? a. the doctor should be reprimanded b. the pharmacy should incorporate bar coding c. the prescription should not count towards the pharmacy's yield

d. the error should be reported to the FDA ✔✔ c. the prescription should not count towards the pharmacy's yield The legal doctrine that assigns responsibility to a doctor for the behavior of his or her employee is: a. Good Samaritan b. Qui Tam c. Respondeat superior d. Res ipsa loquitor ✔✔ c. Respondeat superior Res ipsa loquitor means "the facts speak for themselves" In general, how many steps should a failure modes and effects analysis (FMEA) proceed in each direction? a. one b. two c. five d. ten ✔✔ b. two

Two-part process: 1. identification of errors/defects (failure modes). 2. consideration of consequences (effect analysis). Which piece of legislation mandates the companies with securities listed in the United States abide by generally accepted accounting practices? a. Foreign Corrupt Practices Act b. Emergency Medical Treatment and Active Labor Act c. False Claims Act d. Civil Monetary Penalties Act ✔✔ a. Foreign Corrupt Practices Act Which piece of legislation made qui tam lawsuits possible? a. Fair Labor Standards Act b. False Claims Act c. Freedom of Information Act d. Emergency medical Treatment and Active Labor Act ✔✔ b. False Claims Act The unethical practice of billing for a more expensive service than is actually provided is known as:

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a. upcoding b. DRG creep c. unbundling d. overdiagnosis ✔✔ b. DRG creep DRG Creep refers to upcoding but specifically referring to inpatient hospital billing codes (DRG codes), and the higher reimbursement code is not accurately reflecting the same service provided to patient (DRG codes a very complex). From the example Frank provided below, sprained ankle is not the same as broken ankle. Example from Frank a while back: "you have a cold but the physician bills for treating you with the flu. In other words, you have a sprained ankle but I bill that you have a more complex issue like a broken ankle" Upcoding - the provider may be using the same service/procedure code, but he/she chooses the one that offers higher reimbursement rate. Usually, upcoding is used regarding CPT codes. For instance: the three CPT codes below are for the same service "PT elevation". But you can see there is a minor differentiation, and the higher the complexity, the higher the reimbursement. 97161: PT evaluation - low complexity 97162: PT evaluation - moderate complexity

97163: PT evaluation - high complexity Example from Frank a while back: Upcoding...you receive 15 mins of physical therapy services...but the physician bills for 30 minutes of "advanced" physical therapy services In other words, I give you a hamburger but I bill as if I gave you a steak dinner. Which of the following would result in a healthcare provider receiving a new NPI? a. change of job description b. change last name c. change in work location d. none of the above ✔✔ d. none of the above Which of the following conditions must be met for a patient no longer be deserving of service under EMTALA? a. the patient must have provided the contact information of a person who can care for him or her upon discharge b. the patient must be able to feed himself without special equipment c. the patient must be alert

d. the patient must be able to communicate without special equipment ✔✔ c. the patient must be alert (patient is stable or no longer on emergency medical condition) Which of the following is NOT a possible punishment for a violation of the Stark Law? a. denial of payment for the services provided b. exclusion from Medicare Program c. Fine d. Incarceration ✔✔ d. Incarceration Stark Law applies to civil law only, so incarceration would not be a possible punishment for violation of stark law. However, stark law penalties may include: fines, denial of payment for services provided, refund of money already collected, exclusion from Medicare/Medicaid or other state healthcare program. Research suggests that people make fewer errors when they: a. perform several tasks at once b. work creatively c. work individually

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d. work in a team ✔✔ d. work in a team Which of the following groups reports information to the Healthcare Integrity and Protection Data Bank (HIPDB)? a. federal agencies b. peer review organizations c. hospitals d. medical malpractice payers ✔✔ a. federal agencies In program evaluation and review technique (PERT), the earliest point at which a successor event may follow a prerequisite event is called: a. lag time b. lead time c. critical path d. fast track ✔✔ a. lag time PERT lead time - interval within which a proceeding event must be finished to allow time to complete next step in process. PERT fast track - accelerating processes by performing several activities at once.

And critical path is the minimum duration of the project. Which of the following is NOT one of the prerequisites for the voluntary self-disclosure program administered by the OIG? a. the disclosing party must describe the wrongdoing and the harm that may have been caused to federal programs b. the disclosure may not be the result of investigation or a pending proceeding c. the disclosure must not be the subject of a bankruptcy proceeding d. the disclosure must be on behalf of an individual rather than an entity ✔✔ d. the disclosure must be on behalf of an individual rather than an entity Which of the following is NOT one of the categories of obligations outlined in the Code of Ethics for healthcare compliance professionals issued by the Health Care Compliance Association? a. obligations to the public b. obligations to the government c. obligations to the employing organization d. obligations to the profession ✔✔ b. obligations to the government

Before conducting a safety audit in an emergency department, and administrator first needs to obtain: a. a list of the employees in that department b. a map of the department c. a written set of safety standards d. statistics on adverse events ✔✔ c. a written set of safety standards Which of the following is NOT covered by the Stark Law? a. physician services b. physical therapy services c. clinical laboratory services d. occupational therapy services ✔✔ a. physician services Stark Law is only applicable to Designated Health Services (DHS) The secretary of which federal agency oversees the FDA? a. Occupational Safety and Health Administration b. General Services Administration

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c. Department of Health and Human Services d. Center for Medicare and Medicaid Contractors ✔✔ c. Department of Health and Human Services The Secretary of the Department of Health and Human Services oversees the FDA. It also administers Medicare, Medicaid, NIH, and Administration for Children and Families. In most hospitals, the release of information department is component of: a. acute assessment unit b. medical records department c. emergency department d. health information management services department ✔✔ d. health information management services department According to the Institute of Medicine, which of the following is NOT one of the domains of quality of care? a. government regulation b. customization c. safety

d. interventions consistent with the latest findings ✔✔ a. government regulation The practice of separating claims which should be billed together is known as: a. upcoding b. unbundling c. DRG creep d. kickback ✔✔ b. unbundling A hospital's medication system is vast, and various element of it fall within the purview of several different departments. One important step forwards reducing errors in this system is to: a. make each department responsible for the system as a whole b. have each department use the same self-assessment tools c. give a single person responsibility for overseeing the entire system d. simplify it ✔✔ c. give a single person responsibility for overseeing the entire system Which type of audit is generally recommended for healthcare compliance programs? a. concurrent audit b. baseline audit

c. retrospective audit d. snapshot audit ✔✔ a. concurrent audit In concurrent audit, real-time evaluation, problems are identified and resolved as they emerge. Which piece of legislation applies to claims that were NOT provided as requested? a. False Claims Act b. Civil Monetary Penalties Law c. Employee Retirement Income Security Act d. Balanced Budget Act of 1997 ✔✔ b. Civil Monetary Penalties Law In comprehensive error rate testing (CERT), the proportion of paid and denied claims that are incorrectly handled is known as: a. fiscal liability rate b. total claims error rate c. denied claims error rate d. paid claims error rate ✔✔ d. paid claims error rate

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Medicare contractors use this rate as a quick gauge of how claims errors are affecting Medicare Trust Fund. Which case established that a corporate director may breach his or her fiduciary obligation by failing to faithfully institute a compliance and ethics program? a. Rush Prudential v. Moran (2002) b. Caremark International Derivative Litigation (1996) c. Washington State Medical Association v. Regence BlueShield (2007) d. Medical Association of Georgia v. BlueCross of Georgia (2000) ✔✔ b. Caremark International Derivative Litigation (1996) A civil action concerning a director's duty of care. Caremark directors breached their duty of care by failing to adequately supervise their employees when they knew/should've known a violation of law was occurring. Ref: 698 A.2d 959 (Del. Ch. 1996) Which of the following is NOT one of the criteria categories identified by the Clinical Laboratory Improvement Amendments (CLIA)? a. accuracy b. interpretation and judgement c. calibration, quality control, and proficiency testing materials

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d. training and experience ✔✔ a. accuracy See all FDA-CLIA Categorizations: https://www.fda.gov/medical-devices/ivd-regulatory-assistance/clia-categorizations Which of the following pieces of information is available in the Healthcare Integrity and Protection Data Bank, but not the National Practitioner Data Bank? a. medical malpractice payments b. criminal convictions related to healthcare c. loss of licensure d. negative findings by state certification authority ✔✔ b. criminal convictions related to healthcare Which is the most common reason for a certificate of medical necessity to require recertification? a. change in the health status of the patients b. resupply of oxygen c. failure to renew medical approval d. change of address ✔✔ b. resupply of oxygen

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Which of the following statements about individually identifiable health information (IHI) is false? a. individually identifiable health information (IHI) may relate to future payments for healthcare b. individually identifiable health information (IHI) may be received by an employer c. individually identifiable health information (IHI) provides the patient's name d. individually identifiable health information (IHI) may be created by a healthcare clearinghouse ✔✔ c. individually identifiable health information (IHI) provides the patient's name Identifiable IHI does not necessarily provide patient's name, but it does contain enough identifying information that it may be reasonably that the name of the person can be discovered. Which of the following is responsible for the most privacy violations of HIPAA? a. improper disposal of data b. data disclosed without the authorization of the patient c. loss of data d. physical theft of data ✔✔ d. physical theft of data

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Physical theft data is number one. The second most is data disclosed without the authorization of patient. According to the OIG, which of the following would likely be the least helpful measure for improving outpatient services? a. describe the hospital's post-submission testing process to a fiscal intermediary b. evaluate all possible bills for outpatient services provided at the hospital and within the applicable time period c. implement computer programs to identify outpatient services that are not billed separately from inpatient services d. establish a regular manual review of outpatient service claims ✔✔ a. describe the hospital's post-submission testing process to a fiscal intermediary Which of the following is NOT one of the patient rights enumerated in the Patient Self- Determination Act? a. patients have the right to refuse medical treatment b. patients have the right to facilitate decisions related to their own healthcare c. patients have the right to select their medication d. patients have the right to make advance healthcare directives ✔✔ c. patients have the right to select their medication

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CHC Practice Test Questions and Answers 100

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