Chapter 1: Intro to Healthcare

Question 1

1940

Answer 1

Americans began having healthcare insurance. *insurance wasn’t common until 1940

Question 2

Stabilization Act of 1942

Answer 2

Stabilization Act: placed wage and price controls on employers and allowed the adoption of employee insurance plans

Question 3

Internal Revenue Code of 1954

Answer 3

Internal revenue code: stated employer contributions to employee health plans were exempt from employee taxable income
* Think, its removed from your check prior to taxes

Question 4

07/30/1966 * double check year***

Answer 4

Medicare was passed into law by president Lyndon B. Johnson under SSAct

Question 5

07/01/1965

Answer 5

Beneficiaries could begin to enroll in Medicare
- Automatically enrolled in Part A, Optional to enroll in Part B.

Question 6

HMO act of 1973

Answer 6

Health Maintenance Organization (HMO) act of 1973
- Proposed under the Nixon Administration to help control Healthcare costs
-authorized $375 million to help establish and expand HMO Network

Question 7

PPO

Answer 7

Preferred Provider Organization (PPO) emerged in 1973

Question 8

How are Healthcare Regulations set?

Answer 8

Not always definitive and may vary by payer, geographic area and the setting n which care is provided.

Question 9

What is the HIPPA Act of 1996?

Answer 9

Health Insurance Portability and Accountability Act
- HIPPA Act of 1996: Originally passed to provide rights and protections for participants and beneficiaries of group healthplans and protect the confidentiality and security of HC Information.
- Protected agains discrimination on pre-existing conditions

Question 10

HCFAC (Healthcare Fraud and Abuse Control Program) of 1996

Answer 10

Established by HIPPA to combat fraud and abuse in healthcare including health plans.

Question 11

Privacy Rule

Answer 11

Standards address how an individual’s protected health information (PHI) may be used.
- No restrictions on the use of de-identified health info.
- need ROI authorization to release information

Question 12

PHI: Protected Health Information

Answer 12

“individually identifiable health information”
- common identifiers: demographics, name, address, DOB, S.S., address
- information related to an individuals past, present, or future physical or mental health or condition, or payment provisions.

Question 13

Health Information vs. Individually Identifiable Health Information

Question 14

What are the covered entities under Privacy Rule?

Answer 14

Healthplans, clearing houses, provider.

Question 15

What are Business Associates?

Answer 15

Under Privacy Rule, 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.
*the use or disclosure of PHI between the two parties.

Question 16

HITECH Act

Answer 16

Health Information Technology for Economic and Clinical Health is under the Privacy Rule.
- Specifies that an organization that provides data transmission of PHI to a covered entity and that requires access to PHI routinely, shall be treated as a business associate
- Contract is required
**Think Epic portals, etc.

Question 16

HITECH Act

Answer 16

Health Information Technology for Economic and Clinical Health
- specifies that an organization that provides data transmission of PHI to a covered entity and that requires access to PHI routinely, shall be treated as a business associate
**Think Epic portals, etc.

Question 17

When can PHI be released without written authorization?

Answer 17

1. ROI to a patient requesting their own MR or billing documents
2. for treatment, payment and HC operation activities
3. individual may grant information permission if asked
4. minimum necessary

Question 18

What is Minimum Necessary?

Answer 18

A key protection of HIPPA Privacy Rule which requires covered entities to accomplish the intended purpose with minimal disclosure as possible.

Question 19

Subpoenas vs. Court Ordered MR Requests

Answer 19

Subpoenas issues by a court clerk or attorney (someone other than a judge) is NOT the same as a court order.
Subpoenas should be issued with a court order to release records.
If subpoena is NOT accompanied by a court order:
1. notify individual, giving them the chance to object
or
2. see qualified protective order from the clerk

Question 20

HIPPA Security Rule

Answer 20

To establish national standards to protect and secure patient data that is transmitted electronically.
*Health plans, providers, & clearinghouses.
** Breach notification requires the covered entity to notify the individuals.

Question 21

CoP: Conditions of Participation

Answer 21

CMS and other healthplans have conditions that the health organization must meet in order to participate with the plan or program.
CoP applies to:
ambulatory surgical centers, hospitals, hospice, clinics, longterm care facilities, transplant centers, psychiatric hospitals

Question 22

CMS Medical Records Requirements

Answer 22

• Original MR or legally reproduced MR for 5 years
• Cost reports for last 5 years
• Managed care programs for 10 years
  *state laws on retention can vary depending on provider and age of patient

Question 23

Federal False Claims

Answer 23

Allows claims to be brought up up to 7years or 10 years in some cases

Question 24

Fraud vs. Abuse

Answer 24

CMS defines:
Fraud: (think, Fake)
Making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program
Abuse: (think, Take Advantage of)
An action that results in unnecessary costs to a federal healthcare program; indirectly or directly

Question 25

Criminal Health Care Fraud Act

Answer 25

A scheme to willingly defraud any HC benefit program

Question 26

Reverse False Claims

Answer 26

“oops”
provider must return overpayment within 60 days from the date when the over payment was identifiable

Question 27

Stark Law

Answer 27

“Self referral”= self benefiting
Stark Law prohibits providers from referring to somewhere they own or immediate family owns or they benefit from unless, part of a group referring within the group (think PAR)

Question 28

Anti-Kick Back Law

Answer 28

Think = offering/receiving goods for services. “an exchange”
Knowingly or willingly offering, paying, or receiving any type or rewards for services

Question 29

Truth in Lending Act (TILA) of 1968

Answer 29

To protect consumers in their dealings with lenders or creditors

Question 30

Finance Charge Assessment

Answer 30

• offering credit payable in more than 4 installments is considered a creditor: with or without finance charges
  –> amount if finance charges must be disclosed as an annual percentage rate (think CC statements)
  –> payment plans that exceed 4 installments; practice MUST disclose the following information: “itemized statement” (think CC statement)

Question 31

MACRA of 2015

Answer 31

Created the Quality Payment Program (QPP)
1. MIPS
2. APMs

Question 32

What is the purpose of MIPS?

Answer 32

The goal is to provide a single quality reporting system with a single payment adj factor based on individual or group performance in Medicare Part B
- successful reporters = successful pay adjustments
-performance categories
- ex: 2021 performance year
2022 reporting year
2023 adjustments applied

Question 33

What are some of the QPP Collection Types?

Answer 33

Data collection types:
- eCQMS, QCDR, CAHPS, MIPS, Med Part B measures, Admin Claims measures, CMS interface measures.
** Collectors can use a combo of Collection Types to submit data

Question 34

What are 4 MIPS Categories?

Answer 34

1. Quality of care
2. Promoting interoperability (ex: pt portal, eRX, EMR)
3. Improvement activities (ex: pt engagement and knowledge, being available, etc)
4. Cost (creating efficiencies in medicare spending)[#4 is 30% of total score]

• the higher the MIPS final score = the higher the payment adjustment (more money taken away)

Question 35

What does MVP stand for?

Answer 35

MIPS Value Pathways

Question 36

Adv. Alternative Payment Methods (APM)

Answer 36

APM – A group of clinicians that come together voluntarily in an organized way to deliver coordinated high quality care to MC patients (includes APM approved bundled payments) (think ACO)
– not required to report MIPS
- May get 5% incentive for going over threshold payments

Question 37

What are the 7 main Health Care regulations:

Answer 37

1. HIPPA
2. Conditions of Participation (CoP)
3. Fraud and Abuse
4. False Claims Act (FCA)
5. Stark Law (Federal Laws)
   - Anti-kickback
   - HC Fraud Statute
   6.Truth in Lending Act (TILA)
6. Quality Payment Program (QPP)

Question 38

False Claims Act (FCA)

Answer 38

Protects the government from being over charged or sold substandard goods or services
examples:
- Falsifying medical chart notation
- Upcoming and/or unbundling services
- Submitting claims for services not performed

Question 39

HIPPA Administration Simplification of 2002

Answer 39

Required that sections of the law be publicized to explain the standards for the electronic exchange, privacy, and security of H.I.

Question 40

When was ICD-10-CM Implemented?

Answer 40

2015

Question 41

When was ICD-10-CM Implemented?

Answer 41

2015

Question 42

What are the 6 Code Sets?

Answer 42

1. POS (place of service)
2. HCPCS
3. ICD-10-CM
4. CPT
5. CDT
6. NDC

Question 43

Which code sets are required under HIPPA?

Answer 43

1. CDT for dental
2. CPT and HCPCS Level II for physician/outpt
3. ICD-10-CM for all dx reporting (in/out pt)
4. ICD-10-PCS for inpatient procedures