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Chapter 2
Medical Insurance Study Guide
| Question | Answer |
|---|---|
| What is HIPPA? | Law designed to protect people's private health information, ensures health coverage for workers and their families when they change or lose jobs, and uncover fraud and abuse. |
| What are the three HIPPA Administrative Simplifications? | 1. HIPPA Privacy Rule 2. HIPPA Security Rule 3. HIPPA Electronic Health Care Transaction and Code Set |
| What is covered entity? | Organization that electronically transmit any information that is protected under HIPPA. Health plans, Health Care clearinghouse, and health care providers |
| What is protected health information? | Individual identifiable health information or maintained by electronic media |
| List 5 examples of protected health information? | Name, address, birthdate, telephone number, social security number |
| What type of law state an employer is responsible for an employee's actions? | Respondeat Superior |
| What is the difference between fraud and abuse? | Fraud is the act of deception used to take advantage of another person. Abuse is an action that misuses money that the governement has allocated. |
| In 2006, the federal government recovered an estimated ____ in fraud-related judgements and settlements with companies and individuals? | $2.2 billion |
| What is the National Providers Identifier? | The standard for the identification of providers when filing claims and other transaction. NPI had nine digits and check digit. |
| What are HIPPA National Identifiers? | Employers, Health Care Providers, Health Plans, Patient |
| What are the characteristics of a good password? | Always used a combination of at least 6 letters and numbers that are not real words and not obvious. Do not use user ID as a password. Select a mixture of upper and lowers case letters. Include special characters. Change passwords periodically. |
| What is HIPPAA Security Rule? | Rules that require covered entities to establish safeguards to protect a patients protected health information. |
| What standards make it possible for providers and health plans to exchange electronic data using standard format and standard code set? | HIPPA Electronic Health Care Transaction and Code Set |
| What is the ICD-9-CM Code Set? | Mandated Code Set for diagnosis under TCS? |
| CMS administers the Medicare and Medicaid program for more than ____ Americans. | 90 million |
| Where are patient Medical records stored? | The pharmacy practice. |
| What are the requirements for covered entities under the HIPPA Privacy Rule? | Have a set of privacy practices that are appropriate for its health care services. Notify patients about their privacy right and how their information can be used or disclosed. Train employee so that they understand the privacy practice. |
| What is the Sarbanes-Oxley Act 2002? | Requires publicly trades corporations to attest that their financial management is sound. |
| What is treatment, payment, and health care operations? (TPO) | Term referring to providing and coordinating a patient's medical care, the exchange of information with health plans and general business management functions |
| What means taking reasonable safeguards to protect PHI from incidental disclosure? | Minimum Necessary Standard |
| What is a designated record set? | Medication and billing records a pharmacy maintains. |
| ___is the document explains how a patients protected health information may be used and describing their rights | Notice of Privacy Practices |
| What must a authorization document contain? | A description of the information to be used or disclosed. The name or other specific identification of the person authorized to use or disclose the information. |
| What must a authorization document contain? | The name of the person or group of the people to whom the covered entity may make the use or disclosure. A description of each purpose of requested the use or disclosure. The signature of the individual and the date. |
| What are the exceptions to the usual HIPPA rules? | Court orders, Workers' Compensation Cases. Statutory Reports, Research |
| What is de-identified health information? | Health information that neither identifies nor provides a reasonable basis to identify an individual. |
| What is the process of encryption? | Process of encoding information in such way that only the person or computer with a key can decode it. |
| What is the difference between the NPI and the NCPDP Provider Identifier? | NPI- is an identification for providers when filing claims and other transactions. NCPDP- provides pharmacies with a unique national identifier for use in interactions with payers and claim processors. |
| What is the Medicare Prescription Drug Improvement and Modernization Act of 2003? | Provided seniors and individuals with disabilities access to prescription drug plans with more choices and better benefits under Medicare. |
| What is the Freedom of Choice Law? | Focuses on the plan member and the pharmacy or pharmacist. It allows the member to select a pharmacy of choice, even if it is a non-participating pharmacy. |
| What is Prescription Drug Equity Act? | Prohibits a prescription drug plan from providing mail order coverage without providing non-mail order prescription benefits. |
| What is another name for Whistle-Blower Cases? | Qui tam |
| Who detects health care fraud and abuse and enforces all laws relating to them? | Office of Inspector General (OIG) |
| What is the name of the program that was created to uncover and prosecute fraud and abuse? | Health Care Fraud and Abuse Control Program |
| What is the Antikickback statue? | Makes it illegal to knowingly offer incentives induce referrals for services that are paid by government healthcare programs? |
| Who is the enforcer of HIPPA Privacy Regulations? | Office for Civil Right (OCR) |
| What is respondeat superior? | Law that states an employer is responsible for an employee's action |
| ____are plans a pharmacy practice writes and implements to uncover compliance problem and correct them to avoid risking liability. | Compliance Plans |
| What are the three goals of the compliance plans? | Prevent fraud & abuse through a formal process to identify, investigate, fix and prevent repeat violations relating to reimbursements for health care services. |
| What is an audit? | Methodical examination of selected pharmacy records. |
| What is the difference between subpoena and subpoena duces tecum? | Subpoena - order of the court directing a party to appear and testify. Subpoena duces tecum - order of the court directing a party to appear, testify, and bring specified documents or items. |
| What are three goals of the compliance plans? | Ensure compliance with applicable federal, state, and local laws, including employment and environmental laws as well as Anti fraud laws. |
| What are three goals of the compliance plans? | Help defend the practice if it is investigated or prosecuted for fraud by substantiating the desire to behave compliantly and to thus reduce any fines or criminal prosecution. |
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gfoster32
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