Questions and Answers
Which of the following is a core compliance requirement?
Reporting suspected compliance violations is the responsibility of specific individuals only.
False
What should you do if you suspect a violation of compliance standards?
Report the suspected violation.
Which of the following is NOT a reporting method for employees of a Sponsor to report potential non-compliance?
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The organization's Standards of Conduct should reflect its individual organization’s ________ and business operations.
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Internal audits are informal reviews of compliance with set standards.
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Match the following compliance terms with their descriptions:
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What is a primary action taken immediately after non-compliance is detected?
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Employees of First-Tier, Downstream, or Related Entities should report potential non-compliance to their ______ or Compliance Help Line.
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What is a consequence of non-compliance?
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Ethical standards should be followed only if convenient.
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Match the following compliance actions with their descriptions:
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Who should tailor the Standards of Conduct to their organization?
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What is a core requirement for an effective compliance program?
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Beneficiaries must report non-compliance only through the Medicare Compliance Officer.
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What must organizations do to correct instances of identified non-compliance?
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Which of the following is NOT a core requirement of an effective compliance program?
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All sponsors must allow for anonymous reporting of potential fraud, waste, and abuse (FWA).
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What are the seven core compliance program requirements?
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An effective compliance program should articulate the organization’s commitment to __________ conduct.
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What should be done promptly after identifying FWA?
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An organization can retaliate against an employee who reports compliance violations.
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Name one key indicator of potential fraud, waste, and abuse (FWA).
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Match the following compliance program aspects with their descriptions:
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Study Notes
Reporting Potential Non-Compliance
- Employees of a Sponsor can report by calling the Medicare Compliance Officer, through their organization's website, or via the Compliance Hotline.
- First-Tier, Downstream, or Related Entity (FDR) employees should speak to a manager, call the Ethics/Compliance Help Line, or report directly to the sponsor.
- Beneficiaries may report non-compliance by calling the sponsor’s Compliance Hotline, making reports on the sponsor’s website, or contacting 1-800-Medicare.
Response to Detected Non-Compliance
- Immediate investigation and prompt correction are required once non-compliance is detected.
- Internal monitoring should ensure prevention of recurrence, ongoing compliance with CMS requirements, and the effectiveness of internal controls to protect enrollees.
Internal Monitoring and Audits
- Internal monitoring involves regular reviews to confirm compliance and implement corrective actions as needed.
- Internal audits are formal evaluations of compliance against established standards like laws, regulations, and organizational policies.
Compliance Program Training Summary
- Compliance programs must meet seven core requirements and promote a culture of compliance.
- Adhering to ethical behavior and organizational Standards of Conduct is essential.
- Awareness of common non-compliance issues and reporting methods is crucial.
- Understanding the consequences of non-compliance and participating in corrective actions are required.
Procedures for Prompt Response to Compliance Issues
- Sponsors must implement effective measures for swift response and corrective action upon identifying non-compliance.
Ethical Conduct in the Medicare Program
- Ethical behavior in the Medicare Program includes acting fairly and honestly, adhering to high standards, complying with laws and CMS requirements, and reporting suspected violations.
Understanding Expectations
- Standards of Conduct outline compliance expectations and principles specific to each organization and should be readily available to all employees.
- Reporting non-compliance is a shared responsibility, and organizations should clarify how to report such incidents.
Definition of Non-Compliance
- Non-compliance refers to actions that violate laws, federal healthcare program requirements, or organizational policies.
Impact of Non-Compliance
- Non-compliance poses risks to the organization, emphasizing the need for prevention, detection, and correction programs.
- A mechanism for reporting potential fraud, waste, and abuse (FWA) must exist, ensuring anonymity and protection against retaliation for reporters.
Effective Compliance Programs
- CMS mandates sponsors to maintain effective compliance programs that demonstrate commitment to ethical conduct, provide guidance for compliance queries, and facilitate identification and reporting of violations.
- An effective compliance program is critical in preventing, detecting, and correcting issues related to non-compliance and FWA.
- It should be fully implemented, tailored to the organization’s needs, adequately resourced, and promote clear communication channels for reporting non-compliance.
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Description
This quiz covers the proper procedures for reporting potential non-compliance in Medicare operations. It outlines the responsibilities of employees both at the sponsor level and within first-tier, downstream, or related entities. Test your understanding of compliance reporting protocols and ethical guidelines in healthcare.
