Federal Agencies And Regulations Flashcards
NIH
National Institutes of Health
FDA
Food and Drug Administration
CDC
Centers for Disease Control and Prevention
ATSDR
Agency for Toxic Substances and Disease Registry
IHS
Indian Health Service
HRSA
Health Resources and Services Adminiatration
SAM-HSA
Substance Abuse and Mental Health Services Administration
AHRQ
Agency for Health Research and Quality
CMS
Center for Medicare and Medicaid Services
ACF
Administration for Children and Families
ACL
Administration for Community Living
Quality Improvement Organization (QIO) Program
Administered by CMS to monitor and improve utilization and quality of care for Medicare beneficiaries.
Office of Inspector General (OIG)
Protects the integrity of HHS programs and the health and welfare of the beneficiaries of those programs. Investigate fraud and abuse.
What are the two main governing bodies affecting healthcare change?
CMS and OIG
What are other names for Medicare and Medicaid programs?
Title XVIII and Title XIX
What CMS program is used to monitor and improve utilization and quality of care for Medicare beneficiaries?
Quality Improvement Organization (QIO)
Federal Regulations
-Patient Rights
-Administration Simplification
-Affordable Care
-Anti-Fraud and Abuse
-Telephone consumer Protection
-Credit and Collections
-Patient Anti-Dumping
-Performance Improvement
Patient Rights
A brochure that states what a patient/their family can expect during a hospital stay:
-high quality hospital care
-a clean and safe environment
-involvement in your care
-protection of your privacy
-help when leaving the hospital
-help with your billing claims
HIPAA
The Health Insurance Portability and Accountability Act
PHI
Protected Health Information
Privacy and Security Rules
Issued by HHS as part of HIPAA to protect an individuals’ medical records and other personal health information.
Protected Health Information (PHI)
Any individually identifiable patient information that can be used individually or in combination to patients with medical information. (Examples: name, DOB, address, phone number, email address, SSN, MRN, employer’s name/address, etc.)
Administrative Simplification
A rule made in order to to provide savings for providers that has not yet been seen partially due to payers requiring nonstandard information requirements and patient accounting softwares charging prohibitive fees for Electronic Remittance Advices (ERAs).
ERAs
Electronic Remittance Advices: an explanation from the health plan to provider about claim payment.
PSDA
Patient Self-Determination Act
Patient Self-Determination Act
Passed by congress to ensure patients understand their right to participate in decisions about their own healthcare. Specifically addressing Advanced Directives.
Advanced Directives
Written Statements detailing a patient’s wishes regarding medical treatment in the event they become unable to make certain decisions.
Living Will
A document specifying what treatments a patient does or does not wish to receive. Patients choose the circumstances in which they will die and also regarding organ donation.
Healthcare Power of Attorney/Durable Power of Attorney
A document that designates a healthcare surrogate/agent/proxy for decision making on the patient’s behalf when they are not able to make those decisions.
Do Not Resuscitate (DNR) Order
A document stating a patient does not wish to have CPR or similar interventions performed in the event of a medical emergency.
PPACA
The Patient Protection and Affordable Care Act
Fraud
Intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization.
Example: incorrect reporting for maximized payment, billing for services not furnished, altering claims to receive payment, accepting kickbacks, etc.
Abuse
Incidents or practices of healthcare workers that, although not usually considered fraud, are inconsistent with accepted sound practices.
What administrative sanctions can CMS take if inappropriate/fraudulent behavior have occurred?
- Denial of revocation of the provider number application
- Suspension of provider payments
- Application of Civil Monetary Penalties (CMPs)
TCPA
Telephone Consumer Protection Act
Restricts telephone solicitations and use of automated telephone equipment.
FDCPA
Fair Debt Collection Practices Act
Fair Debt Collection Practices Act imposes and prohibits
Imposes strict limitations on
-acquisition of info regarding debtors locations
-communication with debtor or others in collection of debt
Prohibits
-Harassment or abuse during collection process
-Use of false/misleading info during collection process
-the collector from communicating at an unusual time (typically before 8am or after 9pm)
-the collector from communicating with the debtor if there in known legal counsel representation, unless given consent by attorney to communicate with the debtor.
-communicating with debtor at place of employment if believed that such employer prohibits the consumer from receiving such communication.
ECOA
Equal Credit Opportunity Act
CLIA
Clinical Laboratory Improvement Act
CLIA Requires
That’s all laboratory services furnished to Medicare beneficiaries must be performed by a provider who has a CLIA certificate. Their CLIA number should be listed on the claim submission.
Exemption from certain regulations occur when
When the state law is more stringent or offer more protection for the consumer than the federal laws do.
TJC
The Joint Commission
The Joint Commission
A private agency that seeks to protect and improve the quality and safety of care
TJC surveys what areas for Patient Access
- Distribution and discussion about advanced directives
- Patient rights and responsibilities
- Organizational ethics
- Continuum of care
- Management of environment of care
- Confidentiality
- Privacy
- Security
- Communication
Patient Care Partnership Brochure
Replaced the “Patient’s Bill of Rights”
Was adopted by the AHA
Is a plain-language brochure
