Chapter 1 Flashcards
What is true about health care regulations?
Health care regulations may vary by state and by payer
Rational: not all regulations are federally established and may not always be definitive. Regulations can vary by payer and geographic area. It is important for a CBP to know and adhere to the specific regulations.
In which circumstances may PHI not be disclosed with out the patient’s authorization or permission?
An office receives a call from a PTs husband asking for information about his wife’s recent office visit
What were the eight standard transactions for electronic data interchange adopted under?
HIPAA
Rationale: Under HIPAA provisions were included for Administrative simplification that mandated HHS to adopt national standards for electronic healthcare transactions and code sets. Eight standard transactions were adopted.
Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate?
Minimum Necessary
A new radiology company opens in town. The manager calls your practice and offer to pay $20 for evert Medicare PT you send to them for radiology services. What does this offer violate?
Anti- Kickback Law
A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, What is this consultant considered?
A Business Associate
Rationale: Business Associates perform certain functions or activities, which involve the use or disclosure of individually identifiable health information, on behalf of another person or organization. These services include claims processing or administration, data analysis, utilization review, billing, benefit management, and re-pricing. Because the consultant will be auditing the medical records, PHI will need to be shared from the practice. The practice would be the covered entity.
Patient questions and concern regarding the Privacy Practices in the clinic should be addressed by what party?
Privacy Official
Rationale: HIPAA rules indicate that all entities should designate a Privacy Official that will develop and implement privacy policies and procedures and be a contact person for individuals with questions.
Fraud and Abuse penalties do NOT include which of the following?
-Imprisonment
-Ability to refile claims in questions
-Exclusion from federal healthcare programs
-Monetary penalties
Ability to refile claims in question
Rationale: Fraud & abuse penalties are stiff and can include monetary penalties, exclusions from Medicare, Medicaid, and other federal healthcare programs and even imprisonment.
According to the Privacy Rule, What health information may not be de-identified?
Physician provider number
Medicare overpayments should be returned within what time frame after the overpayment has been identified?
60 days
Which of the following is NOT a component of the Preferred Provider Organizations (PPO) payer model?
Require the enrollee to maintain a PCP
A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue?
False Claims Act
Rationale: CMS states that a false claim is made when someone knowingly presents or causes to be presented, a claim for payment of approval that is not legitimate
A health plan sends a request for medical records to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information?
No, Since the information is used for payment activities it is not necessary to notify or obtain authorization from the patient.
What is the purpose of the Privacy Rule?
To protect the patient
All the following are considered Fraud, EXCEPT:
-Failure to maintain adequate medical records
-Billing every new PT at the highest level E/M visit no matter what
-Falsifying documentation to support a service that was billed to receive payment
-Reporting a diagnosis code that the patient does not have, but is payable by Medicare
Failure to maintain adequate medical records
