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CBCS Review > Revenue Cycle and Regulatory Compliance > Flashcards

Revenue Cycle and Regulatory Compliance Flashcards

1
Q

What is HIPAA?

A

The Health Insurance Portability and Accountability Act of 1996. This is a federal regulation that was designed to provide protection of confidentiality and security for patients. It was also the first rule that standardized patient confidentiality.

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2
Q

What is ARRA?

A

American Recovery and Reinvestment Act

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3
Q

What is HITECH?

A

Health Information Technology For Economic and Clinical Health Act

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4
Q

What is the Stark Law?

A

This law prohibits physician referrals of designated health services for Medicare and Medicaid patients if the physician has a financial relationship with that entity.(immediate family member)

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5
Q

What is the OIG?

A

Office of Inspector General for the United States Department of Health and Human Services(HHS) is dedicated to fighting waste, fraud, and abuse and to improving the efficiency of Medicare and Medicaid by developing guidelines. They have a hotline or website.

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6
Q

What is The Fair Debt Collection Practices Act?

A

(FDCPA) Is a consumer protection amendment, establishing legal protection from abusive debt collection practices. Part of the Consumer Credit Protection Act, as Title VIII.

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7
Q

What is the False Claims Act?

A

It is a federal law that prohibits any person or organization to knowingly make a false record or file a false claim regarding any federal health care program.

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8
Q

What is ROI?

A

Release of Information

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9
Q

What is TPO?

A

Treatment, Payment, and Healthcare Operations

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10
Q

What is NCCI?

A

National Correct Coding Initiative, this program prevents coding errors that could lead to inappropriate reimbursement for Medicare claims.

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11
Q

What is Privacy?

A

It is the patient’s right to have their Protected Health Information(PHI) safe-guarded.

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12
Q

What is an Aging Report(AR)?

A

It is a report of outstanding claims. Claims that have not been paid 30 days or more. The report is divided into 30-day increments. You should work on the oldest accounts first.

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13
Q

What is Accounts Receivable?

A

It is money owed to the provider.

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14
Q

What is the key tool to collecting patient payments?

A

Communication

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15
Q

What is Security?

A

It is controlling access to records, protecting PHI, and giving efficient employee training.

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16
Q

When can you disclose PHI?

A

When the patient has signed an authorization.

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17
Q

What is Fraud?

A

The intentional misinterpretation of health information to receive higher reimbursement.

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18
Q

What is Abuse?

A

The un-intentional misinterpretation of health information to receive higher reimbursement.

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19
Q

What is the best practice when dealing with a Denial?

A

It is to perform an analysis to determine where the errors are occurring.

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20
Q

What should be done once your organization determines where the errors are occurring?

A

Additional training or workflow corrections should be implemented.

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21
Q

What is Revenue Cycle Management?

A

This is the process that health care providers use to manage financial viability by increasing revenue, improving cash flow, from registration to final payment.

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22
Q

Where does communication start?

A

It starts at the point of service, during registration and scheduling, where the information is gathered from the patient to create an account.

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23
Q

When is it important to communicate with the patient?

A

When notifying the patient of their financial responsibility.

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24
Q

Why should there be good communication between the provider and staff?

A

To ensure that medical record documentation meets the assigned code requirements for reporting purposes.

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25
Q

What are the primary Stakeholders?

A

Patients, Providers, Third-Party-Payers, and Policymakers.

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26
Q

What are Providers?

A

They are licensed individuals who can submit claims for services rendered for reimbursement. Providers administer the delivery of care within the policy framework. They also coordinate the patient’s care and maintain their health record.

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27
Q

What are Third-Party-Payers?

A

These are organizations that cover medical expenses of the policyholder and dependants. This includes employers, commercial or private organizations, government programs, Work comp, and homeowner/auto insurance.

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28
Q

What are Third-Party-Payers responsible for?

A

They maintain the financial stability of health care policies and programs. They have administrative processes to analyze premium rates and annual deductibles to meet changes.

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29
Q

What are Regulatory Agencies composed of?

A

Policymakers that develop the rules and guidelines.

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30
Q

What are policymakers?

A

They establish the framework that determines who is eligible to receive care and what services are provided, how, where, and by whom. They determine how services are paid and determine the quality of care standards for the patients.

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31
Q

What are Covered Entities?

A

This is an entity that transmits health information in electronic form(Providers, Health plans, Clearinghouses…)

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32
Q

How long should providers retain HIPAA-related documents?

A

They must keep records for 6 years and 2 years after a patient’s death. Medicare Managed Care patients medical records must be kept for 10 years.

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33
Q

What are the critical components of maintaining data?

A

Back-up & Recovery

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34
Q

What is the Practice Management System?

A

This is a collective source of administrative data within an organization.

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35
Q

What does the Practice Management System include?

A

Health care technological tools to perform operational tasks and the EHR components such as data from patient encounters. (demos, med records, insurance info, and coded data)

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36
Q

What is the Administrative Uses of Data?

A

This includes important operational tasks such as analyzing the number of patients for census purposes to determine how many patients are being treated, population health management, quality improvement, and cost vs. reimbursement analysis.

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37
Q

What are Clinical Uses of Data?

A

This is used to maintain the health and well-being of the population. This data can be used to determine cost-effectiveness, reimbursement decisions, and strategies.

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38
Q

What is Data Storage?

A

This refers to records, files, and documents that are physically or digitally stored for future reference and use. Data is usually stored off-site in case of a disaster.

39
Q

What is Data Transmission?

A

This refers to sending digital information over individual or multiple secure communication channels.

40
Q

What is Electronic Data Interchange?

A

Computer technology contains the exchange of data between the health care provider and payer. i.e. Electronic Remittance Advices or Eligibility

41
Q

What is Data Reporting?

A

This refers to the process of collecting pertinent facts about patient care and outcomes to perform security or other analyses, as well as reporting performance measures for incentive programs.

42
Q

Why is Reporting Data vital to a health care organization?

A

They can assist in making informed decisions that support organizational objectives.

43
Q

What are Guidelines? (Federal, HIPAA….)

A

Guidelines outline how to receive and manage protected information. Other laws and regulations include expectations of an organization to protect patient privacy and how to prevent fraud & abuse.

44
Q

What should be the priority of a Health Care Organization?

A

Complying with Rules & Regulations.

45
Q

Why is Reporting Breaches important?

A

Providers are responsible for safeguarding patient and other stakeholder information.

46
Q

What is the HIPAA Breach Notification Rule?

A

This regulates reporting of impermissible use or disclosure of PHI.

47
Q

What happens if there is a breach and patient information is released?

A

The organization is responsible for taking the appropriate steps to disclose or report the breach.

48
Q

What is a Compliance Plan?

A

This plan addresses compliance rules and regulations of government and private payers. This is a culture that manages and protects the administration of health care services to patients.

49
Q

What does having a formal compliance plan indicate?

A

That the practice is making a good-faith effort to achieve a state of compliance for safe, effective, and efficient care of their patients.

50
Q

What should be referenced when developing a Compliance Plan?

A

The OIG Federal Register to identify potential areas of risk and develop standard practices around the guidelines. Compliance program guidance plans are specified by the type of organization.

51
Q

What is the Federal Register?

A

This is a yearly, published work plan identifying at-risk or emerging issues.

52
Q

What does the OIG offer as components as the foundation of a Compliance Plan?

A
  1. Conducting internal monitoring and audits
  2. Implementing compliance and practice standards
  3. Designating a compliance officer
  4. Conducting appropriate training & education
  5. Responding appropriately to detected violations
  6. Developing open lines of communication(meetings, bulletin boards)
  7. Enforcing disciplinary standards
53
Q

What is the Provider Self-Disclosure Protocol(SDP)?

A

This is a program developed by the OIG for health care providers to self-disclose instances of potential fraud. This protocol is voluntary and implements the compliance plan to support the organization’s culture of safe and effective health care. This lowers the cost and disruption of an OIG-initiated audit. The OIG website includes the SDP submission link.

54
Q

What is Confidentiality?

A

This refers to the protection of patient information from an unauthorized person. This means limiting medical information from being accessed and maintaining private information.

55
Q

What are other practices for Confidentiality & Security?

A
  1. Conducting periodic training on confidentiality protocols

2. Activity monitoring of EHR

56
Q

What is a key protection for the HIPAA Privacy Rule?

A

The Minimum Necessary Standard

57
Q

What is The Minimum Necessary Standard?

A

This standard mandates that covered entities review their practices and safeguards routinely to ensure appropriate access to and disclosure of Protected Health Information(PHI).

58
Q

What does The Minimum Necessary Standard require?

A

It requires that employees be limited to protected information, accessing only the areas of that medical record required to complete their task.

59
Q

What is a Breach of Confidentiality?

A

This is normally unintentional and involves the release and disclosure of patient information to a third party.

60
Q

What are examples of Breaches of Confidentiality?

A
  1. Communicating with staff in a public space
  2. Disclosing information in unattended areas like lab results
  3. Discussing patient information with family without consent
  4. Announcing patient information in the lobby
  5. Retrieving patient information not related to your tasks
61
Q

What do Regulations like Confidentiality & Security ensure?

A

This ensures patients have control of their health information, how it is used, and who it can be shared with.

62
Q

What is the Release of Information?

A

This is a feature of the HIPAA Privacy Rule and is a method of controlling and tracking access to PHI about a patient. this ensures the patient’s privacy is protected while allowing appropriate access to health care services.

63
Q

What should a provider do when the privacy restriction applies?

A

The health care provider should obtain the patient’s signature on a consent form.

64
Q

What are the Elements of a Medical Record Release Form?

A
  1. Identification of organization & patient
  2. Timeframe to identify the service date and admission/discharge date
  3. Information requested to be released
  4. Purpose for the request
  5. Date of request
  6. Original signature from patient/legal guardian
65
Q

What is Implied Consent?

A

This type of consent does not require a signature or any specific documentation in the medical record.

66
Q

What is Informed Consent?

A

This consent includes communicating the nature of the proposed treatment, associated risks, and alternatives, and answering all the patient’s questions. The patient then signs or declines the consent to have the service done.

67
Q

What is Consent?

A

This is an important communication that occurs when a provider explains the risk and benefits of a specific procedure to a patient so they can make an informed decision.

68
Q

What is Written Consent?

A

When a procedure has a significant risk of complication, written consent is signed. This means the patient is giving permission for the procedure to be done.

69
Q

What does HIPAA allow the patient to do with their medical records?

A

Patients can review and receive their medical and billing records. They can also request a change if they find an error.

70
Q

Who can request records?

A

The patient or patient’s representative

71
Q

What is the time frame medical record requests need to be processed?

A

Within 30 days from the date of request. Extensions are permitted if records are archived or stored off-site.

72
Q

What must organizations do regarding record releases?

A

They must maintain a log to document where PHI was released and who the authorized requestors in the event of a breach.

73
Q

When are providers allowed to send records without patient permission?

A

If it is for the use of Treatment, Payment, or Operations(TPO)

74
Q

What is the Treatment in TPO?

A

This is the coordination and management of one’s health care.

75
Q

What is the Payment in TPO?

A

This is the activities related to the provider’s billing and reimbursement.

76
Q

What is the Operations in TPO?

A

These are the administrative processes that are typical for health care organizations.

77
Q

What is a Subpoena?

A

This allows the disclosure, and authorization from the patient is not required.

78
Q

What are Privacy Exceptions?

A

Times when there is a reasonable need to release medical records for legal proceedings, or emergency situations.

79
Q

What is the Privacy Rule exception regarding Psychotherapy notes?

A

Mental health records are kept separate from medical records and will not be released unless the patient has given consent.

80
Q

When are patient records kept confidential?

A

If the patient has HIV/AIDS, to prevent discrimination, but will be disclosed if necessary for treatment. And substance use.

81
Q

What are two important features of the HITECH Act?

A
  1. Promotes the use of EHRs by health care providers

2. Strengthens HIPAA Privacy and Security Rules

82
Q

What can fraudulent billing and coding result in?

A

Severe civil and criminal penalties ranging from fines to imprisonment.

83
Q

What are the 3 main categories of fraud?

A
  1. Billing for services that have not been performed
  2. Reporting fraudulent diagnosis
  3. Purposeful coding errors(unbundling, upcoding…)
84
Q

Can you write off a patient’s out-of-pocket expenses?

A

No, it will be fraud. It is in the provider’s contractual agreement to collect patients out-of-pocket portions.

85
Q

What is the penalty for Abuse?

A
  1. Educational sessions
  2. Recovery of overpayment
  3. Withholding future reimbursement
86
Q

What are the best practices to minimize unintentional claim errors?

A
  1. Accurate & timely documentation
  2. Appropriate code linkage
  3. Accurate code assignments
  4. Correct provider & referring provider information on claim
  5. Correct service date
87
Q

What is Unbundling?

A

This is the process of reporting two separate procedure codes with the intent of reimbursement on two codes when CPT rules state only one code should be used.

88
Q

What are the 3 categories of billing & coding errors?

A
  1. Unintentional billing & coding errors
  2. Unnecessary charges
  3. Billing for non-medically necessary charges
89
Q

What is the Federal Claims Collection Act(FCCA)?

A

This allows Medicare administrative contractors to collect claims overpayments from health care providers and beneficiaries.

90
Q

What are two ways NCCI Edits work?

A
  1. One of the codes is a component of the other code.

2. One of the codes excludes the other by their code description.

91
Q

What are Encounter Forms used for?

A

They are used to bridge the administrative and clinical departments as both contribute elements to the claim.

92
Q

What do Encounter Forms contain?

A

Diagnoses, Services, and Procedures

93
Q

What is Adjudication?

A

The process when clean claims are submitted to the payer is processed and paid according to the individual plan.

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