Broward Health has rolled out a two-hour training program for its fourth year of training, and it focuses less this year on the corporate integrity agreement and more on compliance generally (“Road to Redemption? Broward Health Rebuilds Compliance Program; OIG Cited CIA Problems,” RMC 28, no. 20), says Chief Compliance Officer Brian Kozik. The training emphasizes the seven elements of an effective compliance program, the duty to report and the non-retaliation policy. Below is a quiz people take after training. Contact Kozik at bkozik@browardhealth.org.
CIA Year 4 General Compliance Ethics Training - Assessment
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The purpose of the Compliance Program is to:
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Maintain a culture that promotes integrity, ethical behavior, and Broward’s mission and values.
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Identify and prevent wrongdoing.
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Help ensure all laws, rules and regulations, and policies and procedures are followed.
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All of the above
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Who is responsible for compliance with all laws, rules and regulations, and policies?
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Employees
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Board of Directors
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Chief Compliance Officer
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All of the Above. Responsibility for compliance resides with everyone, including our Board of Commissioners, employees, officers, medical staff, volunteers, contractors, vendors, and agents. All of our activities will be conducted in compliance with all applicable laws, rules and regulations, and policies and procedures.
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Broward Health has a policy that protects individuals who report suspected violations of the Code of Conduct, policies and procedures, or law.
True. Broward Health has a Non-Retaliation Policy (GA-004-035) and will not tolerate any retaliation against an employee who in good faith reports a suspected violation. “In good faith” means the person actually believes that the information reported is true.
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Fraud is knowingly providing false information in order to obtain payment or other benefit to which we would otherwise not be entitled.
True. Fraud is intentionally making false statements in order to obtain payment or other benefits to which we would otherwise not be entitled.
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It is only illegal to give a kickback (i.e., cash or cash equivalents, tickets or trips), not to receive one.
False. The Anti-Kickback Statute applies to both those who give and those who receive kickbacks. Asking for, offering, or receiving a kickback could violate the law.
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Which statement is true?
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Patient abuse can lead to exclusion.
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Fraud is a willful act. Waste and abuse lead to overutilization of government resources.
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Violation of the False Claims Act can lead to imprisonment.
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All of the above
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A hospital or physician practice has requested that a Broward Health employee fax over specific Protected Health Information (PHI), including diagnosis and treatment information, regarding a patient who completed a proper authorization form to release their medical information. This is not an organization to which Broward Health routinely faxes information. May the PHI be faxed to the hospital or physician practice?
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Yes
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No
Yes PHI can be shared with another practitioner of the patient’s for purposes of Treatment under the HIPAA Privacy Rule. But, make sure you 1) verify the requestor’s identity, along with the patient whose information is being requested, and 2) use a Broward Health fax cover sheet.
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Under HIPAA, a patient is not permitted to see their PHI:
False. Patients have the right to see their PHI but they must request the information through the proper channels. Employees who are patients must follow the same protocols patients do to access their own medical records. If you’re an employee, DO NOT access your own medical record. Instead, sign up for the patient portal.
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Who can you speak with if you have a concern about a potential Compliance issue?
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A manager
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Human Resources
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Chief Compliance Officer
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Compliance Hotline
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All of the above
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Managers have which of the following responsibilities under the Compliance Program?
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Demonstrate a commitment to ethical and legal behavior that is consistent with Broward Health’s mission and Compliance Program.
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Be available and approachable so your employees feel comfortable raising issues with you.
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Emphasize the duty to report and non-retaliation policies.
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Deal with the issues raised timely and inform the Compliance Officer as necessary.
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All of the above
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What are some of the penalties for violating Fraud, Waste, and Abuse (FWA) laws?
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Civil Monetary Penalties
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Imprisonment
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Exclusion from participation in all Federal health care programs
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All of the above
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Copies or original records containing PHI may be properly disposed of in the regular hospital waste containers in the hospital.
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True
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False PHI may not be disposed of in regular hospital waste containers.
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Disclosure of PHI must be limited to minimum amount of information in order to correctly complete the request.
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True Disclosure of PHI must be limited to minimum amount of information in order to correctly complete the request.
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False
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A co-worker forgot her new password and requests using someone else’s for just today. Is that okay?
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YES, but only for a limited time
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YES, but only if the supervisor approves it
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YES, but only if the IT Department approves it
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NO, passwords can never be shared, even temporarily
No. Using another person’s password is strictly prohibited under HIPAA, as well as Broward Health’s compliance policies.
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What statement(s) is/are correct with regard to being excluded from federal health care programs?
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No federal health care program payment may be made for any items or services furnished, at the medical direction, or the prescription of an excluded person.
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Exclusions may be imposed for life.
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Healthcare providers may face stiff financial and other penalties for employing or utilizing an excluded person or entity.
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All of the above.
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Who is the Broward Health’s Chief Compliance Officer?
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Gino Santorio
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Alan Goldsmith
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Melanie Hatcher
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Brian Kozik
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None of the above
Brian Kozik is Broward Health’s Chief Compliance Officer. He can be reached at bkozik@browardhealth.org or 954.473.7548.
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Which statement is false?
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Per our Corporate Integrity Agreement, significant overpayments (>$25,000) must be reported to the Office of Inspector General (OIG).
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Broward Health must report annually to the OIG on the status of its compliance program.
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The Chief Compliance Officer may report to the General Counsel.
Feedback: The Chief Compliance Officer may not report to the General Counsel.
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The Executive Compliance Work Group meets monthly.
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Which statement(s) is/are true?
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Hospitals and physicians who violate EMTALA could receive large fines and harsh penalties.
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You do not have to intentionally submit a false claim to violate the False Claims Act.
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Any provider organization that violates Stark must repay all Medicare funds paid under the improper arrangement.
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Broward Health has developed specific policies and procedures to comply with both Stark and the Anti-Kickback Statute.
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All of the above.
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If you violate the Code of Conduct and self-report, under the Non-retaliation policy, you cannot be subject to disciplinary action.
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True
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False However, self-reporting will be considered in determining the severity of the sanctions.
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Which statement(s) is/are true?
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In accordance with the Affordable Care Act (ACA), if we don’t repay overpayments within 60 days of discovery, then we may be subject to penalties under the False Claims Act.
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Every Broward Health contractual arrangement with a physician is a Focus Arrangement.
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The Board Compliance Committee oversees the Broward Health Compliance Program.
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Physicians do not have to comply with all provisions of the Code of Conduct.
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Both a and c.
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None of the above.
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