CHC (CCB) flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Seven Elements

OIG/DOJ framework for effective compliance programs: written standards, compliance leadership, training, communication lines, monitoring and auditing, enforcement and discipline, and prompt corrective action.

Policy vs. Procedure

A policy states the organization's position and required behavior; a procedure describes the specific steps and responsibilities for carrying out that policy.

Standards of Conduct

Organization-wide document stating expected ethical and legal behavior, including coding integrity, privacy, conflicts of interest, and non-retaliation commitments.

Policy Version Control

Tracking each policy's owner, effective date, revision number, approval signature, and scheduled review date so only current approved versions are in use.

Compliance Officer Independence

The compliance officer reports to the board or CEO and is not subordinate to the revenue or financial operations the compliance function monitors.

Compliance Committee Charter

Governance document defining the committee's authority, membership, quorum, meeting frequency, and reporting obligations to the board.

Board Compliance Oversight

Governing body duties include approving the compliance plan, receiving periodic reports, and ensuring adequate resources for the compliance function.

Risk-Based Resource Allocation

Staffing, budget, and audit hours are directed to the highest-scored compliance risks rather than distributed evenly across all areas.

Role-Specific Training

Education tailored to job duties: coders on coding and billing rules, clinicians on documentation and Stark/AKS, and leadership on oversight responsibilities.

Training Completion Tracking

Dated records such as LMS reports or signed attestations showing each workforce member completed required training within the defined window.

Training Effectiveness Measurement

Evaluating training through knowledge assessments, post-training audit error trends, and remediation rates rather than completion counts alone.

Onboarding Training Window

A defined period after hire within which new workforce members must complete required compliance training before performing billable or PHI-related duties.

Non-Retaliation Policy

Prohibits adverse action against individuals who report compliance concerns in good faith; retaliation is itself a reportable compliance violation.

Compliance Hotline

A reporting channel, often anonymous and confidential, that receives compliance concerns and routes them to the compliance function for triage.

Report Triage and Logging

Each report receives a unique identifier, is classified by risk severity, and is tracked to documented resolution and disposition.

Monitoring vs. Auditing

Monitoring is ongoing and often real-time review; auditing is periodic, retrospective, and independent evaluation against defined criteria.

Error Rate Formula

Error rate equals the number of records with at least one error divided by the number of records reviewed, multiplied by 100.

Corrective Action Plan

Documented remediation specifying the root cause, action steps, responsible owner, due date, and follow-up validation of effectiveness.

Audit Sampling Methods

Random, targeted, or stratified selection of records; sample size should support a defensible estimate of the population error rate.

60-Day Overpayment Rule

Identified overpayments must be reported and returned within 60 days of identification under 42 U.S.C. § 1320a-7k(d).

OIG Self-Disclosure Protocol

A formal channel for providers to voluntarily disclose potential fraud to the OIG, which can mitigate penalties and support resolution.

Investigation Documentation

A complete record of intake, scope, evidence, interviews, findings, and disposition, ideally directed through counsel to preserve privilege.

Exclusion Screening

Checking workforce and vendors against the OIG LEIE and SAM at hire and monthly; excluded individuals cannot bill federal programs.

Risk Score Calculation

Assigning each compliance risk a score by multiplying likelihood by impact, then ranking risks into high, medium, and low tiers.

Compliance Risk Register

A log recording each risk's description, owner, rating, mitigation plan, and review date, updated as risks change.

Risk Assessment Triggers

Reassessment occurs annually and after significant events such as mergers, new service lines, enforcement actions, or major regulatory changes.

False Claims Act

Prohibits knowingly presenting false claims to federal programs; remedies include treble damages, per-claim penalties, and qui tam actions.

Anti-Kickback Statute

42 U.S.C. § 1320a-7b(b) prohibits offering or receiving remuneration to induce referrals of federally reimbursable items or services, subject to safe harbors.

Stark Law

42 U.S.C. § 1395nn prohibits physician self-referral for designated health services absent a regulatory exception; it is a strict liability statute.

HIPAA Minimum Necessary

Requires limiting uses and disclosures of protected health information to the minimum amount reasonably needed to accomplish the intended purpose.

NCCI Edits

National Correct Coding Initiative edits identify code pairs that are not separately reportable unless a documented appropriate modifier applies.

Medical Necessity Documentation

The medical record must support that services billed were reasonable and necessary, including the clinical rationale for the level of service.