Prep Test 1

Question 1

Triggered the regulations for standard transactions and code sets, privacy and security of health information and unique health identifiers

Answer 1

Administrative Simplification Section of Title II(HIPAA)

Question 2

Governs the use and disclosure of protected health information (PHI) by covered entities directly and their business associates indirectly. If the organization doesn’t fit the definition of covered entity, regulations don’t apply

Answer 2

What does HIPAA govern and who must comply w/ these new regulations?

Question 3

TPO (free flow of PHI)

Answer 3

T -Treatment a physician can call his/her colleague in another specialty to get input on care being provided.

P- payment physician’s staff can submit bill to insurance companies to obtain payment for services provided.

O- healthcare Operations HCP’s compliance staff

Question 4

Demographic information such as name, address or other contact information, insurance status and date of care. Can be provided w/o authorization for fundraising

Answer 4

Limited PHI

Question 5

P-D-C-A

Answer 5

Plan
Do make plan for next step
Check
Act

Question 6

3 Ways PHI can be used or disclosed

Answer 6

1. ) w/o an individual’s permission
2. ) if the covered entity has given the individual opportunity to object
3. ) only w/ individual’s explicit permission

Question 7

“Snapshot” of the operations from a compliance perspective. Prelim audit that becomes the baseline for cco and managers to judge process in reducing/eliminating potential areas of vulnerability. OIG goal: “to facilitate identification of problem areas and…..

Answer 7

Baseline Audit

Question 8

Suggests offering incentives to those who follow the compliance and ethics program

Answer 8

Federal sentencing guidelines

Question 9

Only allowing employees and others to Access the information that is needed to perform the role in the organization (HIPAA)

Answer 9

Role base access

Question 10

The signal legal entity that needs the covered entity status with both covered and non-covered healthcare activities and designated its healthcare components as required by the privacy rule

Answer 10

Hybrid Entity

Question 11

A clinical integrated setting where the individual typically receives healthcare for more than one healthcare provider allowing participants to share personal health information for healthcare operations

Answer 11

Organized healthcare arrangements (oHCA)

Question 12

Business associate is an individual or corporation person that performs on behalf of the covered entity and functions or actively involved in using or disclosing personal health information and it’s a member of a covered entities workforce. Covered entity may disclose personal health information to the business associate.

Answer 12

True

Question 13

A group of legal Lee separated covered entities that share common ownership or control, ownership exists entities posses 5% or greater ownership interest in another entity. As a group of covered entities to function as one….

Answer 13

Affiliated Covered Entity (ACE)

Question 14

Group every records maintain or or for a covered entity 1.)the medical record and billing recorded about individuals maintained by for the covered HCP2.) the enrollment, payment, claims adjustment and case or medical management records system maintained

Answer 14

Designated Record Set

Question 15

Refers to laws prohibiting hospitals and physicians from referring services to an entity with watch it or he she has a financial relationship

Answer 15

Self referral status; Stark law

Question 16

Explicit regulatory exceptions to otherwise legally prohibited conduct. Federal Safeharbor Regulations specifically center joint ventures and other arrangements concerning hospitals and or physicians which do not violate Medicare fraud and abuse laws.

Answer 16

Safe harbors

Question 17

Prohibits the solicitation receiving offering or paying of any remuneration, directly or indirectly, in cash or in kind, in exchange for a Medicare or Medicaid referral.

Answer 17

Anti-Kickback law

Question 18

The illegal practice of submitting claims individually in order to maximize reimbursement for various test/procedures which are required to be billed together. The government initiative investigating this issue is “project bad Bundle”

Answer 18

Unbundling

Question 19

Authorized by false claim act(FCA) it’s a suit filed by an employee of an organization or whistleblower with the federal government accusing the organization of fraud and abuse. Allows employees to contact government based on original information.

Answer 19

Qui Tam

Question 20

Used in Hyppa to identify the amount of personal health information that can be used or disclosed in a particular circumstance. Only share the minimum amount of personal health information necessary to accomplish the task.

Answer 20

Minimal necessary

Question 21

The heresy of reporting structure within an organization which assumes all issues will be presented first to one’s immediate supervisor.

Answer 21

Chain of command

Question 22

Classification of diagnosis determined by the average cost of treating a particular condition regardless of that…

Answer 22

Diagnosis related groups(DRGs)

Question 23

Factors that can impact the compliance budget:

Answer 23

Training, Poor communication infrastructure, or data processing controls, compensation structures that emphasize financial performance w/ no compliance consideration

Question 24

Publication of the American medical Association which is in the science codes to procedures and services performed by

Answer 24

Current Procedural terminology

Question 25

1996 civil settlement of care or can watch the OIG and pose the CIA precluded Caremark from providing healthcare in certain forms for 5 years. Also suggest failure of corporate directors to admit to a good faith to institute compliance program may be a breach.

Answer 25

Caremark International derivative Litigation

Question 26

Part of the US sentencing commission guidelines for the sentencing of Organizations, a System that adds points for aggravating factors and subtract points for mitigating factors in the Determination of fines imposed for fraud or abuse

Answer 26

Culpability score

Question 27

Covered Entities

Answer 27

1.) Health plan 2.) healthcare clearinghouse 3.) HCP Who transmits any health information and electronic form and can connection with the transaction covered by...

Question 28

Regulations which apply to any claim for an item or service that was not provided as claimed or that was knowingly submitted as false, And which provides guidelines for the levy of fines for each expense

Answer 28

Civil monetary penalties law (CMPL)

Question 29

In 1974 Federal act that exempt self-insured health plans from state law governing health insurance and requires health plans to ride certain information to enrollees

Answer 29

Employee retirement income security act(ERISA)

Question 30

A person or good night station that under and management with HHS under part a of Medicare, process claims, provide services, and issues payments on behalf of private, Federal and health benefit programs or other insurance organizations

Answer 30

Fiscal Intermediary or fiduciary intermediary

Question 31

US agency created in 1964 to end discrimination based on race, religion,sex or national origin and employment. The commissions reviewed and investigates charges of discrimination and found to be true attempt remedy through conciliation or legal mean.

Answer 31

Equal employment opportunity commission(EEOC)

Question 32

The federal agency that manages the federal government property and record including the construction and operation of buildings and procurement and distribution of supplies, among other functions

Answer 32

General Services Administration(GSA)

Question 33

Originally adopted in 1863 during civil war to discover supplies from overcharging the federal government, I station that prohibits anyone from now and leave submitting are causing to be submitted a false or fraudulent claim

Answer 33

False claims act

Question 34

Public or private entity that does any: 1.) process health information received from another entity and non-standard format or containing non-standard data 2.)Receive standard transactions from other entities and processes health information into non-standard format

Answer 34

Healthcare clearinghouse

Question 35

Comprehensive legislation that ensures access to health coverage for those who change jobs or are temporary out of work. Also provides the mechanisms for funding the DOJ and the FBI for Medicare fraud investigation protected health information

Answer 35

Information portability and accountability act (HIPAA)

Question 36

And officer of a federal agency or primary function is to conduct and provides audits and investigations related to operation and procedures overwatch the agency has jurisdiction

Answer 36

Inspector general (IG)

Question 37

An HHS/OIG nationwide review of compliance w/ rules Government positions at teaching hospitals. Records reviewed to determine adequate physicians involvement in practice care according to IL373 (medicare rule re: attending HCP Must be present with supervising physician

Answer 37

Physicians at teaching hospital