CHC (AHE) flashcards
CHC · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Seven Elements of Compliance
- Standards and procedures, oversight, due care in delegation, communication and training, monitoring and auditing, enforcement and discipline, and response and prevention form the framework for an effective compliance program.
- Compliance Officer Reporting Line
- The compliance officer should report to the board or a board committee and have direct access to the CEO to preserve independence from operational management.
- Policy vs Procedure
- A policy states the organization's position on an obligation; a procedure describes the specific steps taken to implement that policy.
- Document Version Control
- Each policy should carry a unique identifier, revision history, approval signature, and effective date, with superseded versions retained per the record retention schedule.
- Role-Based Training
- Training content is tailored to job function, with specialized modules for billing, coding, sales, and clinical staff in addition to general compliance training.
- Training Completion Tracking
- Records should capture learner identity, completion date, content version, and passing score to support audit and effectiveness measurement.
- Monitoring vs Auditing
- Monitoring is ongoing and process-based; auditing is periodic, independent, and sample-based, with findings quantified by error rate and financial exposure.
- Investigation Documentation
- An investigation file should record scope, complaint source, evidence gathered, interviews conducted, conclusions reached, and corrective actions assigned.
- Exclusion Screening
- Screening against OIG LEIE and SAM exclusion lists should occur at hire and periodically thereafter to prevent billing for excluded individuals.
- Corrective Action Plan
- A CAP specifies the problem, root cause, corrective action, responsible party, timeline, and verification method for confirming resolution.
- Anti-Kickback Statute
- The AKS prohibits knowingly offering or receiving remuneration to induce referrals for items or services payable by federal health care programs.
- Stark Law
- The Stark Law prohibits physician self-referral for designated health services unless a specific regulatory exception applies to the arrangement.
- False Claims Act
- The FCA imposes liability for knowingly presenting false claims and permits qui tam relators to sue on the government's behalf.
- HIPAA Privacy Rule
- The Privacy Rule governs use and disclosure of protected health information and grants patients rights over their health information.
- Risk Assessment Scoring
- Risks are scored by likelihood and impact and then prioritized so that monitoring and control resources target the highest-exposure areas.
- Compliance Hotline
- A hotline permits anonymous reporting, is widely publicized, and has documented intake, triage, and investigation procedures.
- Non-Retaliation Policy
- The organization prohibits retaliation against individuals who report concerns in good faith and communicates this protection to the workforce.
- Tone at the Top
- Leadership commitment to compliance is evidenced by communications, resource allocation, and the response to reported issues.
- Board Compliance Oversight
- The board receives regular compliance reports, reviews risk assessments, and approves the compliance plan and program budget.
- Compliance Effectiveness Metrics
- Metrics such as audit error rates, training completion, hotline volume, and remediation timeliness indicate whether the program is operating as intended.
- PDSA Cycle
- Plan-Do-Study-Act is a structured improvement cycle used to test changes and refine compliance processes based on measured results.
- Compliance Committee
- A cross-functional committee including legal, finance, clinical, HR, and operations that meets on a documented schedule to oversee compliance activities.
- Due Care in Delegation
- The organization verifies that individuals to whom authority is delegated have the qualifications and integrity to perform assigned compliance responsibilities.
- Policy Attestation
- Workforce members sign attestations confirming they have read and will comply with the code of conduct and applicable policies.
- Audit Work Plan
- A work plan defines audit objectives, scope, sample size, and criteria before fieldwork begins to ensure consistent and defensible results.
- Discipline Consistency
- Sanctions are applied consistently across job levels, including leadership, and documented centrally to demonstrate program commitment.
- Beneficiary Inducement CMP
- The Civil Monetary Penalties Law prohibits inducements likely to influence a beneficiary's selection of a particular provider or supplier.
- Sunshine Act Reporting
- The Physician Payments Sunshine Act requires reporting of transfers of value to physicians and teaching hospitals to a federal database.
- Risk Refresh Triggers
- Risk assessments are refreshed at least annually and when law, operations, or organizational structure change materially.
- Exit Interview Compliance Value
- Exit interviews can surface unreported concerns and provide leading indicators of culture and compliance program weaknesses.
- Culture Survey Indicator
- Workforce surveys measuring psychological safety and willingness to report serve as leading indicators of compliance program effectiveness.
- Program Gap Analysis
- Periodic reviews compare current practices against the seven elements and applicable guidance to identify and prioritize remediation opportunities.