Governing and Regulatory Agencies

Question 1

HIM

Answer 1

Health Information Management

Question 2

Joint Commission

Answer 2

private non-profit that evals and accredits nearly 15,000 healthcare org and prog in USA. Governed by 29-member Board of Commissioners including physicians, administrators, nurses, employers, labor rep, health plan leaders, quality experts, ethicists, consumer advocate, educators

Question 3

MCare A

Answer 3

Hospital Insurance. cover most inpatient care up to 90 days including hospital, snf, hospice, respite

Question 4

MCare B

Answer 4

Outpatient Insurance. Covers many services provided from physician care, including general exams, lab tests, counseling, therapy, other outpatient

Question 5

MCare C

Answer 5

aka MCare Advantage plan - overrides A, B, D. More comprehensive prog that offered through many private insurance comp and works like a managed care plan

Question 6

MCare D

Answer 6

RX plan. Went into effect 2006. Optional plan that can be purchased

Question 7

DHHS

Answer 7

Dept of Health and Human Services is fed agency gov and regulating healthcare in USA. Under umbrella: office of surgeon general, center for disease control and prevention, centers for medicare and medicaid

Question 8

DHHS moto

Answer 8

Protecting the health of all Americans and providing essential human services, especially those who are least able to help themselves.

Question 9

CMS

Answer 9

Centers for MCare and MCal serivces. Provides assist for 1 in 4 Americans. Administers State Children’s Health Insurance Program. Publishes eligibility guidelines for MCare and works w/individual states to provide guidelines for MCal. Regulations such as HIPAA, and standards for providers re: billing for services

Question 10

MCal

Answer 10

Joint fed/state. Usually for disabled and/or low-income who lack resources. 51.6 million persons.

Question 11

MCare

Answer 11

Gov spons for qualified sr age 65+ and qualified disabled people any age

Question 12

CMA effected by CMS regulations

Answer 12

regulates conduct w/regard to px confidentiality/privacy rights under HIPAA; works jointly with private/public org to provide regulations and standards for handling and transmission of med records; provides reference and resource info with regard to standard of conduct, HIPAA, fraud reporting and prevention

Question 13

OIG

Answer 13

Office of Inspector General mission is to protect integrity of DHHS programs. Reports to both Secretary and Congress any program and management problems with recommendations to correct them. Duties carried out thru nationwide network of audits, investigations, inspections. Proactive and Reactive Audits

Question 14

Proactive audit

Answer 14

audit where OIG is routinely inspecting healthcare provider to make sure documentation and treatment is appropriate [UNDER SURVEY]

Question 15

Reactive audit

Answer 15

audit/inspection carried out in response to tip, complaint, concern brought to attention of OIG

Question 16

OCR

Answer 16

Office of Civil Rights: responsibility to investigate and, when violations are found, forward for prosecution violators of HIPAA

Question 17

Dept of Justice

Answer 17

NOT PART OF DHHS.
Branch of gov tasked with prosecuting criminals who engage in fraud, abusive, discrimination, other law breaking activities. When OCR or OIG investigates and find complaint has merit, info is forwarded to Dept of Justice for investigation and potential prosecution

Question 18

SAMHSA

Answer 18

Substance Abuse and Mental Health Services Administration: may impact employer/you if work is mental health services