CHC Internal Investigations 3 — Questions and Answers
Question 1: What is the PRIMARY purpose of maintaining a detailed investigation log during a healthcare compliance inquiry?
- To satisfy state licensing requirements
- To create a chronological record that supports defensibility and demonstrates thoroughness (Correct answer)
- To share progress updates with all hospital staff
- To calculate investigator billable hours
Correct 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.
Question 2: Under the False Claims Act, what is 'qui tam' as it relates to healthcare investigations?
- A requirement to report fraud to the OIG within 60 days
- A provision allowing private individuals to file suit on behalf of the government and share in any recovery (Correct answer)
- A type of government subpoena for medical records
- A compliance program certification requirement
Correct 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.
Question 3: When conducting a root cause analysis after a compliance investigation, what is the GOAL?
- To assign blame to the responsible employee
- To identify the underlying systemic factors that enabled the violation (Correct answer)
- To calculate financial penalties owed to the government
- To determine which patients were harmed
Correct 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.
Question 4: Which federal agency's Self-Disclosure Protocol should a healthcare organization use when voluntarily reporting Stark Law violations?
- Department of Justice (DOJ)
- Office of Inspector General (OIG)
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- Department of Health and Human Services (HHS)
Correct answer: Centers for Medicare & Medicaid Services (CMS)
CMS administers the Stark Law Self-Referral Disclosure Protocol (SRDP) for voluntary reporting of Stark Law violations.
Question 5: An internal investigation reveals a pattern of upcoding. To calculate the potential overpayment, what statistical method is commonly used?
- Simple random sampling with extrapolation (Correct answer)
- Full universe review of all claims
- Time-series trending analysis
- Stratified purposive sampling without extrapolation
Correct answer: Simple random sampling with extrapolation
Random sampling with extrapolation is the standard method for estimating overpayments across a large population of claims efficiently.
Question 6: What is the significance of the '60-day rule' under the False Claims Act for healthcare compliance investigations?
- Investigations must be completed within 60 days of initiation
- Overpayments must be reported and returned within 60 days of identification (Correct answer)
- Government contractors must respond to subpoenas within 60 days
- Employees must be interviewed within 60 days of a complaint
Correct 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.
Question 7: Which of the following is an example of a 'corrective action plan' element following an internal compliance investigation?
- Firing all employees in the affected department
- Implementing mandatory retraining and enhanced monitoring for the implicated process (Correct answer)
- Ceasing all operations under the investigated service line
- Publicly disclosing the names of employees involved
Correct 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.
CHC Internal Investigations 3
What is the PRIMARY purpose of maintaining a detailed investigation log during a healthcare compliance inquiry?