Domain 5 Questions 1 St Test Flashcards
A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient’s records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?
No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
Yes; this is hospital policy for which HIPAA has no control.
No; the records from the previous hospital are not included in the designated record set but should be released anyway.
Yes; HIPAA only requires that current records be produced for the patient.
No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
When other healthcare providers provide records, it is done to ensure the continuity of care for the individual.
Many covered entities either include the whole file or copies of the file as part of the covered entity’s record, with the assumption that the treating physician has used some or all of the records to decide how to treat the patient.
Any copies that are included with the records of the individual are, therefore, considered part of the individual’s designated record set and should be released (Thomason 2013, 99).
Which of the following justifies the need for an external audit?
It is used to appeal denials.
It replaces the need for internal audits.
It confirms the validity of the internal audits.
It creates a one-time baseline standard.
It confirms the validity of the internal audits.
External audits are performed to confirm that a healthcare organization’s internal audits are valid. In other words they help to ensure and validate that the internal audits identifying all of the compliance issues (Foltz and Lankisch 2020, 517).
When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected?
There is no impact.
The person making the entry in the health record may not be called as a witness in trial.
The incident report likely becomes discoverable because it is mentioned in a discoverable document.
The incident report cannot be discovered even though it is mentioned in a discoverable document.
- The incident report likely becomes discoverable because it is mentioned in a discoverable document.
Hospitals strive to keep incident reports confidential, and in some states incident reports are protected under statutes protecting quality improvement studies and activities. Incident reports themselves should not be considered a part of the health record. Because the staff member mentioned in the record that an incident report was completed, it will likely be discoverable as the health record is already a discoverable document (Fahrenholz 2017a, 89).
A(n)
is imposed on providers by the OIG when fraud and abuse is discovered
through an investigation.
Corporate Integrity Agreement
OIG Workplace
Red Flags Rule
Resource Agreement
Corporate Integrity Agreement
A corporate integrity agreement (CIA) is essentially a compliance program imposed by the government, with substantial government oversight and outside expert involvement in the organization’s compliance activities. The OIG negotiates CAs with healthcare providers and other entities as part of the settlement of federal healthcare program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the
obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other federal healthcare programs (Bowman 2017, 460).
A provider’s office calls to retrieve emergency room records for a patient’s follow-up appointment. The HIM professional refused to release the emergency department records without a written authorization from the patient. Was this action in compliance?
No; the records are needed for continued care of the patient, so no authorization is required.
Yes; the release of all records requires written authorization from the patient.
No; permission of the ER physician was not obtained.
Yes; one covered entity cannot request the records from another covered entity.
No; the records are needed for continued care of the patient, so no authorization is required
Treatment, payment, and operations (TPO) is an important concept because the Privacy Rule provides a number of exceptions for PHI used or disclosed for TO purposes. Treatment means providing, coordinating, or managing healthcare or healthcare-related services by one or more healthcare providers (Rinehart-Thompson 2020b, 253).
Which of the following is the statistical method that can be used to give every claim the same chance of being included in an audit?
Systematic random sampling
Simple random sampling
Convenience sampling
Stratified random sampling
Simple random sampling gives every bill, patient, and so forth the same chance of being chosen (Foltz and Lankisch 2020, 516).
A decreasing CMI is indicative of which trend?
Increasing patient resource intensity
Increasing proportion of surgical patients
Decreasing payment per case
Decreasing cost of living
Decreasing payment per case
A hospital’s case-mix index (CMI) represents the average MS-DRG relative weight for a particular hospital. The CMI allows administration to measure the hospital’s performance based on MS-DRG cases. By analyzing a facility’s CMI a manager is able to compare the CMI against other similar facilities in the area, or the year-to-year changes of the facility in its CMI. A decreasing CMI would indicate that the facility would be receiving decreased payment per case (Gordon, M. L. 2020, 493-494).
Which of the following situations might result in a compliance audit?
Low CMI
High CC/MCC capture rate
Decreased volume
Lower reimbursement
The CC capture rate is the number of patients with CCs compared to all of the patients in the population. With the changes in the CC list and the addition of MCCs in the MS-DRG system, facilities are finding that the CC capture rate is much lower than it had been previously, and new benchmarks need to be established for MS-DRGs. The CC capture rate is a valuable tool in measuring the overall severity of patients served by the facility as a whole or by a particular physician or specialty. Assuming that the coding is accurately completed, the rate can help measure the specificity of physician documentation (White 2021, 166).
The CC capture rate is the number of patients with CCs compared to all of the patients in the population. With the changes in the CC list and the addition of MCCs in the MS-DRG system, facilities are finding that the CC capture rate is much lower than it had been previously, and new benchmarks need to be established for MS-DRGs. The CC capture rate is a valuable tool in measuring the overall severity of patients served by the facility as a whole or by a particular physician or specialty. Assuming that the coding is accurately completed, the rate can help measure the specificity of physician documentation (White 2021, 166).
In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit?
Admission diagnosis and complaints
Chargemaster description
Clinical laboratory results
Radiology orders
Charge master description
One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description for accuracy (Foltz and Lankisch 2020, 513-514; Casto and White 2021, 144).
The goal of coding compliance programs is to prevent:
Accusations of fraud and abuse
Delays in claims processing
Billing errors
Inaccurate code assignments
Accusations of fraud and abuse
The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance (Foltz and Lankisch 2020, 518-519).
Which of the following is a fraud and abuse prevention strategy that can be used by providers to protect themselves from fraud and abuse allegations?
Documentation strategies
Strategies for noncompliance penalties
Strategies developed by the medical staff to enforce compliance
Patient readmission strategies
Documentation strategies
A strong clinical documentation integrity (CDI) program is important to fighting fraud and abuse through the focus on quality and accuracy (Foltz and Lankisch 2020, 513).
The risk manager’s principal tool for capturing the facts about potentially compensable events is the
Accident report
RM report
Occurrence report
Event report
Occurrence report
An occurrence report is a structured data collection tool that risk managers use to gather information about potentially compensable events. Effective occurrence reports carefully structure the collection of data, information, and facts in a relatively simple format (Shaw and Carter 2019, 200).
The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following?
Reporting of claims, initiating an investigation of claims, protecting the primary and secondary health records, negotiating settlements, managing litigations, and using information for claim’s resolution in performance management activities
Risk acceptance, risk avoidance, risk reduction or minimization, and risk transfer
Safety management, security management, claims management, technology management, and facilities management
Risk identification and analysis, loss prevention and reduction, and claims management
Risk identification and analysis, loss prevention and reduction, and claims management
The purpose of the risk management program is to link risk management functions to related processes of quality assessment and PI. The basic functions of healthcare risk management programs are similar for most organizations and include risk identification and analysis, loss prevention and reduction, and claims management (Carter and Palmer 2020, 572).
The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas?
Operative and other invasive procedures, medication management, and blood and blood product use
Blood and blood product use, medication management, and appointment to the board of directors
Medication management, marketing strategy, and blood use
Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use
Operative and other invasive procedures, medication management, and blood and blood product use
Appointments to the Board of Directors is important information, but the Joint Commission requires detailed information on the responsibilities and actions of the Board, not necessarily its composition. The Joint Commission requires healthcare organizations to collect data on each of these areas: medication management, blood and blood product use, restraint and seclusion use, behavior management and treatment, operative and other invasive procedures, and resuscitation and its outcomes (Shaw and Carter 2019, 304, 313).
The Department of Health and Human Services has identified that Community Hospital is guilty of fraud. It was determined that the facility tried to comply with standards, but their efforts failed. What category of fraud and abuse prevention does this fall into?
Reasonable cause
Reasonable diligence
Willful neglect
Willful defiance
Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements (Foltz and Lankisch 2020, 506).
