Remedial Measures and Discipline Flashcards

A healthcare organization learns that a billing coder submitted false claims but passed all internal audits. The BEST long-term corrective measure is:

Answer: Strengthen audit methodologies to detect the type of falsification discovered

When internal controls fail to detect fraud, the corrective measure must directly address the audit gap that allowed the misconduct to persist.

Which of the following BEST describes a 'corporate integrity agreement' (CIA) in the context of remedial measures?

Answer: A binding settlement with the OIG requiring compliance program enhancements and monitoring

A CIA is a formal agreement with the OIG that imposes specific compliance obligations and independent review as a condition of continued participation in federal healthcare programs.

During a compliance investigation, legal counsel invokes attorney-client privilege over certain documents. The compliance officer should understand that privilege:

Answer: Covers communications between attorney and client made for the purpose of legal advice

Attorney-client privilege applies specifically to confidential communications between a licensed attorney and their client made for purposes of obtaining legal advice.

An employee subject to discipline has the right to 'due process' in a healthcare compliance context. This PRIMARILY means:

Answer: The employee receives notice of allegations and an opportunity to respond before final action

Due process in the employment context means the employee is informed of the specific allegations and given a meaningful opportunity to respond before discipline is finalized.

A compliance officer is designing a corrective action plan after an overpayment is identified. Which component is MOST important to include to satisfy CMS expectations?

Answer: Identification of the root cause and systemic controls to prevent recurrence

CMS expects corrective action plans to identify root causes and implement systemic controls that will prevent similar overpayments in the future.

Under the 60-day rule established in the ACA, once an organization has identified an overpayment it must report and return it within:

Answer: 60 days of identification

The ACA's 60-day rule requires that identified Medicare and Medicaid overpayments be reported and returned within 60 days of quantification.

When disciplining a licensed clinical professional for a compliance violation, the organization should also consider:

Answer: Whether the violation triggers mandatory reporting to the relevant state licensing board

Many states require healthcare organizations to report certain practitioner misconduct to licensing boards, creating an obligation beyond internal discipline.