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ch 2 Flashcards

1
Q

What are the 2 main governing bodies affecting healthcare changes, and are part of what US Department?

A

CMS, Centers for Medicare and Medicaid Services & OIC - office of Inspector General - These are part of the HHS Health and Human Services.

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2
Q

What Organization protect the health of all America and is responsible for providing essential Human Services

A

Health and Human Services - HHS

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3
Q

Which organization oversee the Medicare and Federal portions of the Medicaid programs, State Children’s Health Insurance Program, the Health Insurance Marketplace and related Quality Assurance activities?

A

CMS - Center for Medicare and Medicaid Services, which oversees Medicare programs, Medicaid programs, State Children’s Health Insurance Program, the Health Insurance Marketplace and Related Quality Assurance Activities.

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4
Q

Wat organization is responsible for developing rules and regulations that govern Medicare and Medicaid

A

CMS - responsible for developing rules and regulations that govern Medicare and Medicaid.

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5
Q

What program administered by the CMS monitors and improves utilization and quality of care for Medicare beneficiaries?

A

QIC Quality Improvement Organization

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6
Q

What is the QIO program of and what does it maintain?

A

QIO consist of national network responsible for each state that maintains:
1 - quality improvements
2 - health information management
3 - statistical analysis
4 - computer programming and operations
5 - communications
6 - public relations and marketing
7 - clerical support

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7
Q

What divisions are under the CMS?

A

. . . .CMS
/ | \ \
Medicare/Medicaaid Child Health health insuranceMarket Place QIO

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8
Q

What is the OIG required to review?

A

The OIG is required to review:
1 - all written quality of service complaints submitted by Medicare beneficiaries and/or their representatives
1 - Review/Address whether the services met professional recognized standards of healthcare & if services were provided in appropriate settings

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9
Q

All results of investigations done by the OIG are submitted to whom?

A

HHS - OIG reports to the HHS

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10
Q

What is the mission of the OIG?

A

The mission of the OIG - Office of Inspector General, is to Protect

1- the integrity of HHS
2 - the Health and Welfare of the beneficiaries of these programs

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11
Q

What is the major role of the OIG?

A

The major role of the OIG is to prevent Fraud and Abuse in the HHS organization

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12
Q

Name 2 main governing bodies affecting Healthcare change?

A

CMS and OIG

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13
Q

Name the 2 federal agencies of the HHS

A

CMS and OIG

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14
Q

Name the three Operating Divisions of the HHS

A

1 - Food and Drug Administration FDA
2 - Administration for community Living ACL
3 - Administration for Children and Families ACF

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15
Q

What are the other names for Medicare and Medicaid respectfully?

A

Title XVII and XIX

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16
Q

What is the CMS program that monitors and improves utilization and quality care for Medicare Beneficiaries?

A

QIO Quality Improvement Organization

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17
Q

What areas are regulated in the Federal Healthcare industry

A

1 - Patient rights
2 - Administrative simplification
3 - Affordable Care
4 - Anti-fraud and abuse
5-Telephone Consumer Protection
6 - Credit and Collections
7 - Patient anti-dumping
8 - Performance Improvement

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18
Q

What organization adopted the Patient Bill of Rights?

A

American Hospital Association AHA adopted the Bill of rights

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19
Q

What expectations do the Bill of Rights set and protect?

A

The stated expectations set forth by the Bill of Rights is – a patient and their families can expect a standard of care as to how they will be treated in a healthcare situation.

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20
Q

What replaced the Patient Bill of Rights?

A

The Patient Bill of Rights was replaced by AHA, American Hospital Assoc. with a brochure called
the Patient Care Partnership.

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21
Q

What areas of expectation was set forth in the Bill of Rights replacement document?

A

According the the Patient Care Partnership, during a hospital stay a patient can expect:
1 - Hight Quality Hospital Care
2 - A clean and safe environment
3 - Involvement inn their own care
4 - Protection of their privacy
5 - Help with leaving the hospital
6 - help with their Billing claims

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22
Q

What 2 Main areas are covered in the Patient Care Partnership?

A

1 - Right to Privacy and Security of Heath Information
2 - Right to Participation in Treatment decisions.

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23
Q

What Act created a Federal Standard for Insurers, Health Maintenance Organizations, employers and self-insured:

A

HIPPA Health Insurance Portability and Accountability Act creates a FEDERAL standard for insurers

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24
Q

What do the Privacy and Security Rules govern and what Act issued it?

A

HHS issued the Privacy and Security Rules as part of the HIPAA which governs the safety of the internet and other forms of electronic information exchange.

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25
What National standard was created by HIPAA?
the HIPAA privacy rule created national standards for the safe and accurate exchange of patient information
26
Name 5 benefits of the HIPPA Privacy Rules?
1 - patients have greater control over health information 2 - sets boundaries/guidelines on health records 3 - establishes appropriate safeguards to protect the privacy of health information 4 - it holds violators accountable with civil and criminal penalties 5 - it strikes a balance when public responsibility supports disclosure of some forms of data ie, to protect public heath
27
What benefits do patients receive from the Privacy Rule?
1 - enables patients to find out how their information ay be used and or disclosed 2 - it generally limits release of information to the minimum 3 - it generally gives patients the right to examine/obtain their own health records, and request corrections. 4 - It empowers individuals to control uses and disclosures of their health records.
28
What is PHI - give examples
PHI is Protected Health Information under HIPAA include: 1 - name 2 - DOB 3 - address - email address 4 - phone number 5 - Social Security Number 6 - Medical record number, employer, serial numbers of pacemaker, photographs, fingerprints...
29
When may PHI be shared?
PHI may be shared without explicit consent for: 1 - treatment. 2 - payment, 3 - healthcare operations
30
Can PHI be shared with Police are involved?
PHI CANNOT be shared for marketing purposes or with law enforcement agencies with out consent or proper notification to the patient, except under court order.
31
What are vendors who handle PHI for providers expected to do?
Vendors, such as collection agencies, who handle PHI on behalf of providers must sign a business associate agreement that obligates them to treat PHI on the same basis as covered entities.
32
Because the impact of the HIPAA privacy rule to the patient Access Department / Front Office is immense, who bears the responsibility?
Confidentiality of patient information is the responsibility of every employee, not just the front off or those dealing with medical records.
33
Why has the Administrative Simplification not progressed as it was expected when drafted up.?
Administrative Simplification is not quick due to non-standard information in situational fields, and due to most payers have not standardized their information requirements.
34
What ACT was passed by congress to ensure that patients understand their right to participate in decisions in their own healthcare and to provide a means to ensure it?
Congress passed the Patient Self-Determination Act - PSDA to ensure that patients understand their right to participate in their own healthcare. PSDA provides a means to ensure it.
35
What does the PSDA act address?
PSDA Patient Self-Determination Act address Advance Directives
36
What are Advance Directives?
Advance Directives are written statements of patients wishes regarding medical treatment in the event he/she becomes unable to make certain decisions, DNR
37
Give 3 examples Advance Directives?
Advance Directives are: 1 - DNR 2 - living will 3 - Healthcare Power of Attorney or Durable Power of Attorney - designation of an individual to make decisions on the patient's behalf
38
What is the most significant regulatory overhaul to the US Healthcare system since Medicare in 1965?
The passing of the 1 - Patient Protection and Affordable Care Act PPACA together with the 2 - Health Care and Education Reconciliation ACT HCERA
39
PPACA is primarily aimed at?
The Patient Protection and Affordable Care Act aims at decreasing the number of uninsured Americans and reducing overall costs of healthcare
40
What mechanisms do the PPACA provide to employers and individuals to increase Healthcare coverage rates?
PPACA provides a number of mechanisms to employers and individuals aimed at increasing coverage rate 1 - Mandates 2 - Subsidies 3 - Tax Credits
41
What additional reforms are aimed at improving healthcare outcomes and streamlining the delivery of healthcare by the PPACA?
PPACA requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or gender
42
What are examples of medical fraud:
Fraud includes - 1 - incorrect reporting of diagnosis and procedure codes to maximize payments. 2 - Billing for services not furnished 3 - Altering claims to receive payment 4 - Accepting Kickbacks 5 - Routine waiver of deductible and coinsurance amounts
43
List 5 examples of Abuse in the medical profession:?
Examples of Medical profession abuse are: 1 - Excessive or unwarranted use of technology, pharmaceuticals and services 2 - Abuse of authority and privacy confidentiality or duty to care 3 - Improper billing practices, like billing Medicare instead of Primary insurer 4 - increasing charges to Medicare beneficiaries but not to other patients 5 - unbundling of services and unnecessary transfers of patients
44
What is the difference between Fraud and Abuse?
FRAUD - described the intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization. ABUSE - describes incidents to practices of healthcare workers that although not usually considered fraudulent are inconsistent with accepted sound practices
45
What is the FCA -- False Claims ACT?
The FCS False Claims Act - prohibits making a false record or statement to get a false/fraudulent claims paid by the government, submission of false/fraudulent claims, conspiring to have false/fraudulent claims paid by the government
46
What administrative sanctions may be taken to address the issues of inappropriate/fraudulent behavior on the part of providers?
Various Administrative sanctions may be taken to address false/fraudulent issues, these include: 1 - Denial or revocation of provider number application 2 - Suspension of provider payments 3 - Application of Civil Monetary Penalties
46
TCPA - describe
Telephone Consumer Protection Act is restricts placed on telephone solicitations - telemarketing - and the use of automated telephone equipment. It prohibits contact with a debtor on a cell phone using automated dialing equipment without express consent and limits the use of artificial or prerecorded voice messages. SMS - (short message service, or text) messages, and fax machines
47
Due to the shift in the industry to increase patient responsibility healthcare providers are offering what?
Credit and payment plans and must comply with applicable laws governing credit and collections
48
What is the Truth in Lending Act and what is another name for it?
Truth and Lending Act TLA --- Regulation Z -deals with 1 - disclosure of information before credit is extended, 2 - Requires annual % rates APR and finance charges are clearly and conspicuously identified 3 - written disclosures must be provided to the consumer
49
What protect consumers from inaccurate or unfair practices by issuers of open-ended credit?
The Fair Credit Billing Act
50
How does the FCBA protect consumers
it is requires the creditor to inform debtors (patient) of their rights and of the responsibilities of the creditor. (patients rights creditors responsibility)
51
What ACT was created to defines 1 - what information from "consumer reports" can be used, 2 - by whom it may be used, 3 - when it can be used
FCRA - FAIR CREDIT REPORTING ACT
52
What provides the maximum protection of a consumer's right to privacy and confidentiality of credit reports?
FCRA - FAIR CREDIT REPORTING ACT
53
What act was passed as a result of evidence that debt collectors were using abusive , deceptive, and unfair collection practices
FDCPA - FAIR DEBT COLLECTION PRACTICES ACT
54
On what does the FDCPA impose strict limitations?
the FDCPA imposes strict limitations on: 1 - Acquisition of information regarding the location of the debtor 2 - Communications with the debtor or others i collections of a debt
55
What does the FDCPA prohibit?
The FDCPA prohibits: 1 - Harassment or abuse in the collection process 2 - Use of false or misleading information in the collection process - prohibits collectors from communicating with the consumer * from any unusual time or place or at a time or place which proved inconvenient to consumer - unless prior approval from debtor * If collector knows legal counsel represents the debtor, unless an attorney consents to communication with debtor * at consumer's place of employment, if collector has reason to believe the consumer's employer prohibits the consumer from receiving such communications
56
What prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age , or because someone receives public assistance..?
ECOA - Equal Credit Opportunity Act these facts may be asked but not used in determination processes
57
List 6 restrictions creditors must follow when screening for credit
1 - Discourage person from applying 2 - discriminate 3 - Impose different terms or conditions based on discriminations - 4 - Ask for Martial status when applicate is applying for separate, unsecured account 5 - Ask about spouses detail except: * If spouse is applying with person * If spouse will be allowed to use account * If person is relying on spouse's income or an alimony or child support income from former spouse * If person lives in community property state
58
If any one feels discriminated what should they do?
report it to the appropriate government agency
59
What is Patient Anti-Dumping
When hospital refuses to treat patients without insurance and even transferring them to other facilities and leaving then there, often without notifying the receiving facility
60
What ACT deals with Anti-Dumping
EMTALA - The Emergency Medical Treatment and Active Labor Act - also know as Federal Anti-Dumping Statute.
61
What general requirements are established by the EMTALA:?
Hospitals mush 1 - Medical screening examinations 2 - Necessary stabilizing treatment 3 - Restricting Transfer until stabilization 4 - Must give medical screening exam prior to gathering basic demographic info or question as to how they will pay
62
What ENTALA Regulations are applied to ED vs other locations on hospital campus / and to which patients?
These apply to ALL locations and ALL patients
63
What Amendment requires all Clinical Laboratory services furnished to Medicare Beneficiaries to be performed by a provider who has a Said Certification?
Clinical Laboratory Improvement Amendment CLIA requires Certification and providers to be certified The qualifying provider is issued a CLIA number and should be reported on the claim.
64
Give an example of when a state may be exempt form the CLIA? Name the 2 states exempt
When the States legally requirements are equal to or more stringent that CLIA statutory and regulatory requirements. Washington and New York
65
TJC
The Joint Commission -
66
What is the TJC
The Joint Commission - a private agency that seeks to protect and improve quality and safety of care.
67
Who allows the TJC to accredit hospitals
CMS allow TJC to accredit hospitals. 1 - inspects facilities 2 - provides education on issues affecting patient care and safety 3 - has many standards to protect quality ad safety.
68
Are all hospitals accredited by TJC and if not who accredits them?
no, some are by their states or other agencies
69
When does the TJC runs audits on Hospitals and Labs?
Hospitals 39 months, labs 24 months (2years)
70
When may the organization TJC audit healthcare facilities?
AS early as 9 - 30 months after the initial audit without advanced notice
71
What can the Patient Access area expect TJC surveys:
1 - Distributions and discussion about advanced directives 2 - Patient rights and responsibilities 3 - Organizational ethics 4 - Continuum of care 5 - Management of environment of care 6 - Confidentiality 7 - Privacy 8 - Security 9 - Communication
72
Which of the following is true of the Patient Care Partnership? (Select all that apply.)
It replaces the “Patient’s Bill of Rights.” It was adopted by the AHA. It outlines what a provider can expect from a patient. It is a plain-language brochure. It addresses patient expectations from admission to dismissal only.
73
Which of the following is true of protected health information (PHI)? (Select all that apply
It refers only to any single piece of data that could directly match patients with their medical information. It can be shared without explicit consent for treatment, payment, or healthcare operations (TPO). It cannot be shared for marketing purposes without explicit consent. It cannot be shared with law enforcement agencies without consent or proper notification to the patient, except under court order.
74
The savings resulting from HIPAA’s administrative simplification rules have exceeded initial projections.
❑ True ❑ False
75
Which of the following is not an example of an advance directive? (Select onE)
Living Will Patient Care Partnership brochure Healthcare Power of Attorney or Durable Power of Attorney for Healthcare DNR Order
76
Which of the following is not an example of an administrative sanction for inappropriate/fraudulent behavior on the part of a provider? (Select one.)
Denial or revocation of the provider number application Suspension of provider payments Application of CMPs Inclusion in a published “watch” list of providers
77
Which of the following is true of TJC? (Select one.)
All hospitals must be accredited by TJC. TJC will conduct an audit of a hospital every 39 months. TJC will conduct an audit of a laboratory every 36 months. TJC can audit a healthcare facility without advance notice as early as 6 months after its initial audit.

CRCS (3 decks)

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