Form Center

2. Corporate Compliance Training Video and Acknowledgement Form

   Submission of this form is your legally binding acknowledgement that you have viewed the training material.

   Please view the Training Video, then complete the Acknowledgement Form below

   
   

4. Electronic Signature Agreement*

   By checking the "I agree" box below, I acknowledge that I have viewed the Compliance training video on this date. I have been provided with the opportunity to ask any questions that I may have. I acknowledge that I have received and read a copy of the Compliance Plan and the Code of Conduct. I understand that I must comply with the Compliance Plan, the Code of Conduct, all laws, regulations, policies and procedures, and guidance provided. I understand that I must report any instances of possible violations of the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures to a member of management or the Compliance Officer. I understand that Madison County maintains a hotline for confidential or anonymous reporting of possible violations of the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures. I understand that my failure to comply with the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures or to report possible violations may result in disciplinary action, up to and including termination.

   
   

   1. I agree.
6. Electronic Signature*
7. Today's Date*
   Today's Date
9. Department*
11. 1. _________________________ requires specified Medicaid providers to have an effective compliance program in order to participate in the Medicaid program*

    1. Center for Disease Control and Prevention
    2. New York State
    3. Washington DC
    4. Government Accountability Office
13. 2. The acronym OMIG stands for:*

    1. Organization for Medicare Insurance Governance
    2. Official Medicaid Investigators Group
    3. Ohio Mutual Insurance Group
    4. Office of the Medicaid Inspector General
15. 3. The purpose of the Corporate Compliance Program is to assure proper handling of medicare/medicaid and other insurance programs to detect ______, _______, and ______ in these programs.

    1. health, happiness and human error
    2. physical health, mental health and disability
    3. fraud, waste and abuse
    4. failure, fatigue and violations
17. 4. Which of the following are considered appropriate billing practices?*

    1. Billing for services not provided
    2. Billing for the level of service that is medically necessary
    3. Misrepresenting the service that was provided
    4. Billing for non-covered services as covered items
19. 5. How can Madison County ensure that its billing and coding practices comply with all laws, regulations, guidelines, and policies?*

    1. Code and bill only for services actually provided
    2. Analyze payments systematically and reconcile any over-payments
    3. Ensure all claims are accurate and correctly document the services rendered
    4. All of the above
21. 6. Madison County has a policy that protects individuals who report suspected violations of the Code of Conduct, policies and procedures, or law.*

    1. True
    2. False
23. 7. Who is expected to comply with the Compliance Program policies and procedures?*

    1. All personnel, volunteers and others working for or on behalf of the County
    2. Board Members, Management, and the Compliance Officer
    3. Agents and Contractors
    4. All of the above
25. 8. Madison County has a Compliance Hotline.*

    1. True
    2. False
27. 9. Which of following situations would constitute a conflict of interest? (Select all that apply)*

    1. Making a decision required as part of your duties that could be influenced by a financial or other gain to you or a family relative
    2. Participating in a government audit
    3. Directly supervising a family member as a contractor or employee
    4. Using County facilities for personal use
    5. Obtaining outside employment that interferes with your job responsibilities
29. 10. How can one promptly report a potential violation of law, regulation or policy, or file a complaint?*

    1. Contact direct supervisor
    2. Contact the Corporate Compliance Officer
    3. Call the Compliance Hotline
    4. All of the above
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field