CCT OIG Compliance Guidance 4 — Questions and Answers
Question 1: The OIG's 'permissive exclusion' authority differs from mandatory exclusion in that:
- Permissive exclusion applies only to physicians, not entities
- The OIG has discretion whether to exclude based on the specific facts (Correct answer)
- Permissive exclusions are automatically reversed after one year
- Only state Medicaid agencies can impose permissive exclusions
Correct answer: The OIG has discretion whether to exclude based on the specific facts
Permissive exclusions allow the OIG to weigh circumstances and decide whether exclusion is appropriate, unlike mandatory exclusions triggered automatically by conviction.
Question 2: According to OIG compliance guidance for hospitals, which department most commonly generates high-risk billing areas?
- Human resources
- Emergency departments and outpatient services (Correct answer)
- Facilities management
- Marketing and communications
Correct answer: Emergency departments and outpatient services
OIG hospital CPGs consistently flag emergency departments and outpatient services as high-risk because of complex coding, observation vs. inpatient decisions, and high claim volumes.
Question 3: What is the primary distinction between the False Claims Act and the Anti-Kickback Statute in OIG enforcement?
- The FCA covers only intentional fraud while the AKS applies to negligent billing
- The FCA targets false or fraudulent claims to government programs; the AKS targets corrupt payment arrangements (Correct answer)
- The AKS is a civil statute while the FCA is exclusively criminal
- The FCA applies only to hospitals; the AKS applies to all providers
Correct answer: The FCA targets false or fraudulent claims to government programs; the AKS targets corrupt payment arrangements
The FCA imposes liability for submitting false or fraudulent claims to federal programs, while the AKS prohibits corrupt remuneration arrangements intended to generate referrals.
Question 4: OIG guidance recommends that compliance programs conduct regular internal monitoring and auditing primarily to:
- Satisfy external accreditation bodies such as The Joint Commission
- Detect and correct compliance problems before they escalate or are discovered externally (Correct answer)
- Generate documentation to shield executives from personal liability
- Replace the need for annual independent external audits
Correct answer: Detect and correct compliance problems before they escalate or are discovered externally
Ongoing monitoring and auditing allow organizations to identify and self-correct issues proactively, reducing exposure and demonstrating a commitment to compliance.
Question 5: Which OIG safe harbor protects discounts offered by vendors to purchasers of healthcare goods or services?
- The personal services and management contracts safe harbor
- The discount safe harbor (Correct answer)
- The practitioner recruitment safe harbor
- The waiver of coinsurance safe harbor
Correct answer: The discount safe harbor
The discount safe harbor protects price reductions given by sellers to buyers if the discount is properly disclosed and appropriately reflected in the buyer's cost reports.
Question 6: Under OIG guidance, when should a compliance officer escalate a detected compliance issue to the organization's board?
- Only when federal investigators have already contacted the organization
- When the issue is significant, systemic, or involves senior management (Correct answer)
- Exclusively when the issue involves patient safety events
- After the issue has been fully investigated and resolved internally
Correct answer: When the issue is significant, systemic, or involves senior management
OIG guidance emphasizes board-level oversight, requiring that significant, systemic, or executive-level issues be escalated promptly to ensure appropriate governance.
Question 7: The OIG's 'Physician Self-Referral Law' (Stark Law) guidance addresses situations where:
- A physician refers Medicare or Medicaid patients to an entity with which the physician has a financial relationship (Correct answer)
- A physician submits claims for services not rendered to any payer
- A physician accepts cash payments from patients in lieu of insurance billing
- A physician prescribes controlled substances outside the usual course of practice
Correct answer: A physician refers Medicare or Medicaid patients to an entity with which the physician has a financial relationship
The Stark Law prohibits physicians from referring Medicare/Medicaid patients to entities where the physician or an immediate family member has a financial relationship, unless an exception applies.
CCT OIG Compliance Guidance 4
The OIG's 'permissive exclusion' authority differs from mandatory exclusion in that: