Regulatory Compliance

Question 1

What is the Office of the Inspector General (OIG)?

Answer 1

A division of the US Department of Health and Human Services (HHS) responsible for protecting the integrity of HHS programs and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse; improving program efficiency and effectiveness; and holding accountable those who do not meet requirements or who violate federal. healthcare law.

Question 2

What are the two major programs under HHS?

Answer 2

Medicare and Medicaid.

Question 3

How does the Office of the Inspector General (OIG) help the public protect themselves?

Answer 3

By educating about fraudulent schemes and how to report suspicious activities.

Question 4

What are the more common fraud laws?

Answer 4

The Stark Law, the Anti-Kickback Statute, and the False Claims Act.

Question 5

How does the Office of the Inspector General (OIG) define compliance?

Answer 5

A dynamic process that helps to ensure that hospitals and other healthcare providers are better able to fulfill their commitment to ethical behavior, as well as meet the changes and challenges being imposed upon them by Congress and private insurers.

Question 6

What does establishing a voluntary compliance program and designated compliance officer enable hospitals to do?

Answer 6

Improve the quality of patient care; substantially reduce fraud, waste, and abuse; and reduce the cost of healthcare to federal, state, and private health insurers.

Question 7

What are elements of a Compliance Program?

Answer 7

I. Establish compliance standards, procedures, and policies
II. Assign oversight responsibility to an individual high in the organization’s structure
III. Screen and evaluate employees, physicians, vendors
IV. Communicate, educate, and train on compliance
V. Monitor, audit, and establish internal reporting systems
VI. Discipline for non-compliance
VII. Respond appropriately and immediately to detected offenses.

Question 8

What components of compliance standards and procedures might impact Patient Access services?

Answer 8

Code of Conduct, Admission Policy, Discharge Policy, Patient Referrals, Physician Agreements, Claim Development

Question 9

What are examples of special areas at high risk for non-compliance?

Answer 9

Billing for items or services not rendered, providing medically unnecessary services, upcoming, outpatient services rendered in connection with inpatient stays, duplicate billing, unbundling, patients’ freedom of choice, credit balances

Question 10

What is one way patients can convey their desires concerning their health care?

Answer 10

Advance Directive

Question 11

What is the Patient Protection and Affordable Care Act (PPACA)?

Answer 11

US federal statute signed in 2010 and administered under HHS with the purpose of reforming healthcare in the U.S. in terms of affordability, quality, and availability. Often shortened to the Affordable Care Act (ACA) or “Obamacare.”

Question 12

What are some provisions of the ACA?

Answer 12

Ensuring access to health insurance and protecting against unaffordable out-of-pocket costs, eliminating lifetime benefit limits, providing assistance to those with pre-existing conditions, extending dependent coverage to age 26, expanding Medicaid coverage to more low-income Americans, reducing the prescription drug coverage gap (“donut hole”) for those under Medicare Part D, requiring coverage of preventative services and immunizations, establishing internet portals to assist with identifying coverage options (“The Exchange”)

Question 13

What was the main goal of PPACA?

Answer 13

To increase the amount of Americans who have access to affordable healthcare.

Question 14

What is the Emergency Medical Treatment and Labor Act (EMTALA)?

Answer 14

A federal law enacted 1986 by the Centers for Medicare and Medicaid Services (CMS) to protect patients against discrimination, regardless of ability to pay, and mandating that patients must receive a medical screening exam (MSE) and stabilizing treatment when seeking emergency medical care or in active labor.

Question 15

Why was EMTALA necessary?

Answer 15

EMTALA or the “Anti-Dumping Statute” was necessary because many hospitals believed indigent patients should receive care through charitable organizations or through uncompensated care hospitals and would transfer patients without adequate screenings or stabilization.

Question 16

How might organizations interpret EMTALA?

Answer 16

Some allow registrar to ask for insurance card and copy it before patients receives MSE (screening exam), others may determine that registration must wait. Either way, MSE or stabilizing treatment cannot the delayed to inquire about payment status.

Question 17

Under EMTALA, can payment be accepted prior to treatment if the patient or family volunteers?

Answer 17

No.

Question 18

When is an EMTALA investigation conducted?

Answer 18

EMTALA surveys are complaint-driven: investigations are conducted in response to a complaint about emergency services care.

Question 19

What law protects consumers by prohibiting debt collectors from using unfair, abusive, or deceptive practices while attempting to collect from a consumer?

Answer 19

The Fair Debt Collection Practices Act (FDCPA)

Question 20

Who enforces the Fair Debt Collection Practices Act (FDCPA) and what does it restrict?

Answer 20

The Federal Trade Commission (FTC), how and when collection attempts and contact can be made with consumer.

Question 21

What are debt collectors required to do under the Federal Debt Collection Practices Act (FDCPA)?

Answer 21

Identify themselves, notify the consumer that the communication is an attempt to collect a debt in every conversation, advise that any information collected will be used to aid in the collection of the debt, notify the consumer of their right to dispute the debt in full or in part, with the creditor.

Question 22

What act requires companies to maintain/honor the National Do Not Call (DNC) Registry and a company-specific NDC list, to provide their name, the company they are calling for, and a means to contact them if requested, and prohibits them from calling residences prior to 8 a.m. or after 9 p.m. without previous consumer consent?

Answer 22

The Telephone Consumer Protection Act of 1991 (TCPA).

Question 23

What are other names for an Advance Directive?

Answer 23

Medical Directive, Healthcare Directive, Living Will

Question 24

What is an Advance Directive?

Answer 24

A legal document in which a person outlines what they would like done if they are no longer able to make decisions for themselves due to incapacity or illness.

Question 25

What specific type of living will authorized a specific person to make decisions on a person’s behalf when they have become incapacitated?

Answer 25

A Durable Power of Attorney.

Question 26

What federal agency under the Department of Health and Human Services (HHS) administers Medicare and partners with state governments for administration of Medicaid and other programs, including the Children’s Health Insurance Program (CHIP)?

Answer 26

The Centers for Medicare and Medicaid Services (CMS)

Question 27

What CMS rules are of particular importance to Patient Access professionals?

Answer 27

Rules concerning registration, Meaningful Use, payers, medical necessity, fraud, and abuse.

Question 28

What act originally focused on regulations related to health insurance portability, meaning that once a person has insurance coverage, when changing coverage the previous coverage may be used to reduce or eliminate any pre-existing condition exclusions that might apply under the new plan?

Answer 28

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Question 29

Who is responsible for enforcement of HIPAA regulations?

Answer 29

The Office of Civil Rights (OCR)

Question 30

What provisions of HIPAA are intended to reduce costs and administrative burdens of healthcare through the standardization of electronic administrative and financial transactions?

Answer 30

The Administrative Simplification (AS) provisions

Question 31

What do Administrative Simplification provisions of HIPAA include?

Answer 31

Standards for Privacy, National Provider Identification (NPI), Transaction and Code Sets, Employer Identification (EID), Security and Electronic Signature Standards

Question 32

What are some basics of HIPAA privacy rules?

Answer 32

The creation of a national set of standards for the use and disclosure of an individual’s protected health information (PHI), an individual’s right to understand and control how their health information is being used, and rules applying to health plans, healthcare clearinghouses and all healthcare providers who hold individual identifiable health information or transmit information electronically

Question 33

What standard means that people should only access, use, or disclose the health information that is minimally necessary to accomplish a given task or purpose?

Answer 33

The Minimum Necessary Standard

Question 34

Opening up a patient’s information out of curiosity is a ______________. Willfully sharing that information with others who are not authorized to have the information is a _____________________.

Answer 34

HIPAA violation, serious HIPAA violation

Question 35

What type of information is considered to be PHI?

Answer 35

Anything that can be considered personally identifiable information (PII): patient name, address, Social Security number, Driver’s license number, account or encounter numbers, date of birth, phone numbers, insurance policy numbers, names of relatives, computer IP addresses, email addresses, biometric identifiers, full-face photographic images

Question 36

What is one recommended strategy to secure electronic protected health information (ePHI)?

Answer 36

Encryption on laptops, tablets, and removable storage devices

Question 37

What is a HIPAA breach and what must be done in response to one?

Answer 37

The use or disclosure that compromises the security or privacy of a patient’s protected health information (PHI). Following a breach, notification must be provided to the affected individuals. If the breach is over 500 individuals, notice to the media must be provided and a notice to the Secretary of HHS.

Question 38

What act was created to stimulate the adoption fo electronic health records (EHR), offering providers financial incentives for demonstrating meaningful use of EHR and adding data breach notification rules and increased penalties and fines to ensure EHR technology does not compromise HIPAA security and privacy laws?

Answer 38

The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)

Question 39

Under what provision can a patient request that a healthcare organization not disclose medical information to the patient’s insurance company?

Answer 39

The “Restricted Disclosure” or “HITECH Omnibus”

Question 40

What is required if a healthcare organization is not to disclose information about a service to an insurance company?

Answer 40

The patient must pay for the service in full out fo pocket at the time of service.

Question 41

What right of access to medical information does the patient have under the HITECH Omnibus?

Answer 41

The individual has the right to a copy of their PHI in electronic format, or a hard copy if the file format requested is not readily available, in a timely manner (normally 30 days). The patient cannot be charged more than a reasonable labor cost and cannot be charged a fee for locating the data.

Question 42

How can a Patient Access professional protect a patient’s PHI?

Answer 42

Interview the patient in private whenever possible, never discuss patient information in public, lock computer when away from desk, be sure all mobile devices are secure, have computer screens facing away from public view, never throw items containing PHI in the trash, never share passwords, never let someone use a computer while you are signed on, never look up a patient’s information unless your role dictates

Question 43

What standards specifically deal with protecting credit card personally identifiable information (PII)?

Answer 43

Payment Card Industry Data Security Standard (PCI DSS)

Question 44

How can Patient Access professionals protect cardholder information?

Answer 44

Never copy a patient’s credit card, obtain and enter credit card information in a private place, only use encrypted devices, never write down cardholder data, remove all receipts from the printer promptly

Question 45

How many people did Medicare insure in 2015, and how many of those were over age 65?

Answer 45

Over 55 million, approximately 46 million

Question 46

What incentive program was established as part of the HITECH Act to provide monetary incentives for the adoption and meaningful use of health information technology and qualified electronic health records (EHR), setting specific objectives that health organizations must achieve to qualify for incentive programs?

Answer 46

Meaningful Use

Question 47

What does Meaningful Use allow patients to view?

Answer 47

Their electronic health information, orders and discharge instructions, and up-to-date problem list with current and active diagnosis, allergy, and medications lists, immunization results, lab results, and advance directive information

Question 48

What goals does providing Meaningful Use technology achieve?

Answer 48

Improves quality, safety, and efficiency; reduces health disparities; engages patients and family; improves care coordination and population and public health; maintains privacy and security of patient health information

Question 49

What CMS rule states that for inpatient stays to be reimbursable under Medicare Part A, the stay must cross two midnights?

Answer 49

The Two-Midnight Rule

Question 50

How are inpatient stays of less than two midnights reimbursed?

Answer 50

Under Medicare Part B as an outpatient.

Question 51

What rule does CMS use to track and monitor occurrences in which a patient is admitted as an inpatient but, upon review, it is determined that the services did not meet inpatient criteria and the admission is changed to observation (OBS)?

Answer 51

Condition Code 44