Internal Investigations Flashcards
7 cards from real CHC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Internal Investigations flashcards as text
What is the PRIMARY purpose of maintaining a detailed investigation log during a healthcare compliance inquiry?
Answer: To create a chronological record that supports defensibility and demonstrates thoroughness
A detailed investigation log creates a contemporaneous record that demonstrates the investigation was conducted fairly, thoroughly, and in good faith.
Under the False Claims Act, what is 'qui tam' as it relates to healthcare investigations?
Answer: A provision allowing private individuals to file suit on behalf of the government and share in any recovery
Qui tam provisions of the FCA allow whistleblowers (relators) to sue on behalf of the government and receive a portion of any funds recovered.
When conducting a root cause analysis after a compliance investigation, what is the GOAL?
Answer: To identify the underlying systemic factors that enabled the violation
Root cause analysis focuses on identifying systemic issues and process failures to prevent recurrence rather than assigning individual blame.
Which federal agency's Self-Disclosure Protocol should a healthcare organization use when voluntarily reporting Stark Law violations?
Answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the Stark Law Self-Referral Disclosure Protocol (SRDP) for voluntary reporting of Stark Law violations.
An internal investigation reveals a pattern of upcoding. To calculate the potential overpayment, what statistical method is commonly used?
Answer: Simple random sampling with extrapolation
Random sampling with extrapolation is the standard method for estimating overpayments across a large population of claims efficiently.
What is the significance of the '60-day rule' under the False Claims Act for healthcare compliance investigations?
Answer: Overpayments must be reported and returned within 60 days of identification
The ACA's 60-day rule requires providers to report and return identified overpayments within 60 days to avoid FCA liability for retaining them.
Which of the following is an example of a 'corrective action plan' element following an internal compliance investigation?
Answer: Implementing mandatory retraining and enhanced monitoring for the implicated process
Corrective action plans address root causes through targeted remediation such as retraining, policy revision, and enhanced oversight.