Chapter 16 - Fraud and Abuse Compliance / Chapter 17 - Management

Question 1

noncovered services

Answer 1

Healthcare services that are not reimbursable under a healthcare plan. These services vary by medical plan. Some examples of healthcare services that might be considered noncovered are cosmetic surgery such as liposuction and breast augmentation. Infertility treatments, weight loss programs, mental health services, and dental services are treatments and procedures that are not typically covered by medical insurance.

Question 2

three levels of effort in fraud or abuse prevention

Answer 2

Healthcare providers must make a concerted effort to comply with best practices regarding reimbursement and monitoring for fraud and abuse. Best practices include monitoring and auditing. When HHS determines the civil monetary penalties for the instance of fraud or abuse, the level of efforts that a healthcare provider or healthcare organization has put into fraud and abuse prevention is considered. These efforts can be grouped into the three categories that follow:

1. Reasonable cause. It would be unreasonable to expect the healthcare provider to comply with the requirements of HIPAA
2. Reasonable diligence. The healthcare ­provider has taken reasonable actions to comply with the legislative requirements
3. Willful neglect. Intentionally failing to comply with or being indifferent to the HIPAA provisions

Question 3

concerted

Answer 3

1. mutually contrived or agreed on
2. performed in unison
3. music: an artistic form of auditory communication incorporating instrumental or vocal tones in a structured and continuous manner

Question 4

contrive

Answer 4

1. devise, plan
2. to form or create in an artistic or ingenious manner
3. to bring about by stratagem or with difficulty

Question 5

devise

Answer 5

1. to form in the mind by new combinations or applications of ideas or principles: INVENT
2. to plan to obtain or bring about: PLOT
3. law: to give (real estate) by will

Question 6

complex review

Answer 6

A Recovery Audit Contractor (RAC) review that involves the detailed review of health records by a qualified healthcare coder or clinician as the type of review warrants.

If the RAC review identifies an improper payment, overpayment or underpayment, the healthcare ­provider is sent an informational ­letter that describes the RAC determination. Letters describing complex review findings are more detailed than those describing automated and semi-automated review determinations and also include information to assist providers in avoiding future billing errors. The letters regarding overpayments include instruction to refund the improper payment.

Question 7

automated review

Answer 7

Recovery Audit Contractor (RAC) reviews performed electronically rather than by humans.

Question 8

semi-automated review

Answer 8

Recovery Audit Contractor (RAC) reviews that start with an automated review but also incorporate health record documents analyzed by humans.

Question 9

clinical validation audits

Answer 9

A type of audit conducted to determine if health records contain the necessary documentation, such as lab results, diagnostic test results, operative reports, and so forth to support the diagnoses made by the physician.

Question 10

What are the three types of sampling techniques used in an audit?

Answer 10

Simple random sampling: This model gives every bill, patient, and so forth so that each has the same chance of being chosen.

Systematic random sampling: In this model, a pattern such as selecting every 10th patient admitted is used.

Convenience sampling: In this model, the bills, for example, are chosen based on which ones are available to the auditor.

Question 11

coding compliance plan

Answer 11

A coding compliance plan focuses on the rules and guidelines specifically related to coding and the responsibility of coders. It should contain the same components as the healthcare organization’s compliance plan but with the focus on coding.

Question 12

query (medical coding)

Answer 12

a communication tool or process used to clarify documentation in the health record

Question 13

Medicare Fraud Strike Force

Answer 13

a multi-agency team of United States federal, state, and local investigators who combat Medicare fraud through data analysis and increased community policing

Question 14

Medicaid Fraud Control Units (MFCU)

Answer 14

Groups that investigate and prosecute Medicaid fraud as well as patient abuse and neglect in healthcare facilities.

Question 15

What are the seven principles of organization?

Answer 15

Managers at all levels use the following principles of organization to manage in an effective manner:

Unity of command. In this management principle, each employee reports to one manager. The employees in the scanning department report to the scanning department supervisor and the supervisor reports to the HIM director.

Span of control. The number of employees a person manages is called the span of control and is influenced by the size of the organization (such as a department with only two employees compared to a department with 100 employees), the skill level of the employees (entry-level employees require more supervisor time), and the responsibilities of the supervisor and employees. Span of control can be high, where there are a lot of employees to manage, or low, with few employees to manage. High span of control may cause the manager to be ineffective because too many people report to him or her, or a manager with low span of control may feel he or she is not being used effectively and is capable of more responsibility.

Specialization. All employees have special qualifications or skills that allow them to perform their job to the best of their ability; managers who employ this principle assign work among their reporting employees according to their specialization, such as assigning the most complex coding cases to the coder who has the highest quality performance on coding reviews. The manager can divide and conquer the work of the department using each employee’s strengths, which results in a positive outcome for the healthcare organization.

Delegation. The process by which managers distribute work to the employees of the department along with the authority to make decisions and to act on those decisions.

Directing. The process of assigning the tasks for the day to employees and providing training, instructions, and advice to help with accomplishing the responsibilities.

Coordinating. The process of ensuring activities happen in the order they need to. It is important, for example, for the coding process to be completed before the billing is performed.

Controlling. Performance is monitored in accordance with policies and procedures and changed based on the situation at hand at each moment of the day.

Question 16

organizational behavior

Answer 16

a field of study that explores how people act within organizations and their behavior individually, in a group, and collectively across a department

Question 17

cultural competence

Answer 17

the ability to accept and understand the beliefs and values of other people and groups

Question 18

organizational structure

Answer 18

the framework of authority and supervision for the employees within the organization

Question 19

middle management

Answer 19

managers who are below the top level of management, and who are responsible for controlling and running an organization rather than making decisions about how it operates

Question 20

supervisor

Answer 20

A supervisor oversees the day-to-day performance of employees. Depending on the company, a supervisor may manage a team, a shift or an entire department.

Successful supervisors have excellent organizational and communication skills. These skills help them transfer information from upper management to employees and communicate their teams’ performance or needs to high-level managers. In most cases, supervisors are experts in their field and can efficiently manage daily operations as a result.

Question 21

strategic planning vs operational planning

Answer 21

The strategic plan of a healthcare organization is a map to the future state of the company. The plan outlines the outcomes and goals for the long range. Strategic planning involves how the organization will react to changes in the external environment in the foreseeable future. Usually the time frame is three to five years into the future. In the healthcare environment a strategic plan must take into consideration any federal, state, and local regulations, laws, and accreditation standards that affect the organization currently and in the foreseeable future.

Operational planning is the specific day-to-day tasks required in operating a healthcare organization or an HIM department. The operational plan is the road map to guide a healthcare organization or department toward the goals of the strategic plan. The operational plan is a shorter and more defined time frame than the strategic plan. Department managers are involved in creating an operational plan for their departments to propose how to staff and accomplish the work tasks for the coming year. Supervisors use operational planning on a daily basis to organize the work of their teams to keep up with department workload.

Question 22

organizational chart

Answer 22

An organizational chart, sometimes called an org chart, is a visual graphic or diagram showing the structure and reporting relationships between positions, departments, and employees of an organization.

Question 23

internal analysis

Answer 23

a review of the inner working of the organization to determine strengths and weaknesses of the business practice and process

Question 24

external analysis

Answer 24

an analysis that involves exploring the factors outside the control of the organization to determine what is happening in the market that the organization is a part of

Question 25

market assessment

Answer 25

a thorough analysis of the market to check the needs and requirements of any new or existing idea, product or service before making strategies to start working on it and investing in it

Question 26

SWOT analysis

Answer 26

In a SWOT analysis, key leadership personnel determine the strengths of the organization (what the company does well) and the weaknesses (areas for improvement), and establish future opportunities (and evaluate threats to those opportunities). An example SWOT analysis performed by an HIM department found the following:

Strengths. Coders are all credentialed

Weaknesses. Staff is not trained in a new information system that is being implemented within the next three months

Opportunities. The new information system will increase productivity in the department by 45 percent

Threats. Some members of the staff are opposed to change and there is a time delay with implementing the new information system

Remember, SWOT is an acronym for Strengths-Weaknesses-Opportunities-Threats.

Question 27

change management

Answer 27

the formal process of introducing change, adopting the change, and diffusing it throughout the organization

Question 28

workflow

Answer 28

the process and steps it takes to complete a task

Question 29

workflow analysis

Answer 29

The process of examining an organization’s workflows, generally for the purpose of improving operational efficiency. It involves a review of all subprocesses related to a specific operation. It identifies areas of process improvement such as redundant tasks or processes, inefficient workplace layouts and bottlenecks in the workflow.

Question 30

job description

Answer 30

a list of duties, reporting relationships, working conditions, and responsibilities for a particular job

Question 31

job classification

Answer 31

Job classification is a system that is designed to classify all jobs within a company and put them in a standardized scale based on the overall tasks, responsibilities, pay level, and duties associated with a specific job. Grades or job classification levels are often assigned to each job so that it can be properly organized and categorized within the company.

Question 32

job evaluation

Answer 32

the process of comparing a job against other jobs within the organization to determine the appropriate pay rate

Question 33

job analysis

Answer 33

Job analysis (also known as work analysis) is a family of procedures to identify the content of a job in terms of the activities it involves in addition to the attributes or requirements necessary to perform those activities. Job analysis provides information to organizations that helps them determine which employees are best fit for specific jobs.

Question 34

Answer 34

called a program evaluation and review technique (PERT) chart
(also called project evaluation and review technique (PERT) chart)

The program evaluation and review technique (PERT) is a statistical tool used in project management, which was designed to analyze and represent the tasks involved in completing a given project.

Numbered rectangles are nodes and represent events or milestones.
Directional arrows represent dependent tasks and must be completed sequentially.
Diverging arrow directions (e.g. 1-2 & 1-3) indicate possibly concurrent tasks.
Dotted lines indicate dependent tasks that do not require resources.

Question 35

cash accounting vs accrual accounting

Answer 35

Cash accounting recognizes transactions only when payment is exchanged.

Accrual accounting is an accounting method where revenue or expenses are recorded when a transaction occurs rather than when payment is received or made.

Question 36

budget variance

Answer 36

A difference in the budgeted revenue or expense amount; for instance, an HIM manager budgeted $10,000 for training coders during the current year and training actually cost the department $11,500.

Therefore, the department has a negative budget variance of $1,500. Ideally, a positive variance occurs when the projected revenue is higher or the expenses are lower than projected, meaning the expenditures are within or below the amount that was budgeted.

Question 37

resource allocation

Answer 37

a process and strategy of deciding where resources should be used to achieve the mission, values, and goals of the organization

Question 38

mergers

Answer 38

business situations where two or more companies combine

A merger may entail a consolidation where two entities combine to form one new entity (the surviving entity), or it may be an acquisition where one entity acquires part or all of the assets of the other; or it may be a stock acquisition where one entity acquires the stock of the other entity.

Question 39

four types of time in a PERT chart

Answer 39

PERT has defined four types of time required to accomplish an activity:

optimistic time: the minimum possible time required to accomplish an activity (o) or a path (O), assuming everything proceeds better than is normally expected

pessimistic time: the maximum possible time required to accomplish an activity (p) or a path (P), assuming everything goes wrong (but excluding major catastrophes).

most likely time: the best estimate of the time required to accomplish an activity (m) or a path (M), assuming everything proceeds as normal.

expected time: the best estimate of the time required to accomplish an activity (te) or a path (TE), accounting for the fact that things don’t always proceed as normal (the implication being that the expected time is the average time the task would require if the task were repeated on a number of occasions over an extended period of time).

Question 40

PERT chart activities and sub-activities

Answer 40

Besides events, PERT also knows activities and sub-activities:

PERT activity: the actual performance of a task which consumes time and requires resources (such as labor, materials, space, machinery). It can be understood as representing the time, effort, and resources required to move from one event to another. A PERT activity cannot be performed until the predecessor event has occurred.

PERT sub-activity: a PERT activity can be further decomposed into a set of sub-activities. For example, activity A1 can be decomposed into A1.1, A1.2 and A1.3. Sub-activities have all the properties of activities; in particular, a sub-activity has predecessor or successor events just like an activity. A sub-activity can be decomposed again into finer-grained sub-activities.

Question 41

PERT chart events

Answer 41

In a PERT diagram, the main building block is the event, with connections to its known predecessor events and successor events.

PERT event: a point that marks the start or completion of one or more activities. It consumes no time and uses no resources. When it marks the completion of one or more activities, it is not “reached” (does not occur) until all of the activities leading to that event have been completed.

predecessor event: an event that immediately precedes some other event without any other events intervening. An event can have multiple predecessor events and can be the predecessor of multiple events.

successor event: an event that immediately follows some other event without any other intervening events. An event can have multiple successor events and can be the successor of multiple events.