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Healthcare Compliance Exam

Role-Based Access Only allowing employees and others to access the information that is needed to perform their role in the organization (HIPAA)
Organized Health Care Arrangement (OHCA) A clinically integrated setting where the individual typically receives health care from more than one health care provider. Allows participants to share PHI for health care operations
Affiliated Covered Entity (ACE) A group of legally separate covered entities that share common ownership or control. Common ownership exists if an entity or entities possess 5% or greater ownership interest in another entity. Allows a group of covered entities to function as 1
Hybrid Entity A single legal entity that meets the covered entity status w/ both covered and noncovered health care activities and designates its health care components as required by the Privacy Rule
Business Associate Bus. Assoc. is an individual or corp "person" that performs on behalf of covered entity any function or activity involving use or disclosure of PHI and isn't a member of the covered entity's workforce. Covered entity may disclose PHI to a bus. assoc
Minimal Necessary Used in HIPAA to identify the amount of PHI that can be used or disclosed in a particular circumstance. Only share the minimal amount of PHI necessary to accomplish the task
Designated Record Set Group of records maintained by or for covered entity that is i. the medical records & billing records about individuals maintained by or for the covered HCP; ii. the enrollment, pymt, claims adjudication & case or medical mgmt records systems maintained b
Limited PHI Demographic information such as name, address or other contact information, insurance status and date of care. Can be provided w/o authorization for fundraising
TPO (free flow of PHI) Treatment-A physician can call his colleague in another specialty to get input on care being provided. Payment-Physician's staff can submit bill to individual's insurance co. to obtain pymt for service provided. HealthCareOperations-HCP's compliance staff
3 ways PHI can be used or disclosed 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
What does HIPAA govern & who must comply w/ these new regulations? Governs the use and disclosure of protected health information (PHI) by "covered entities" directly and their business associates indirectly. If the org. in question doesn't fit definition of covered entity, regulations don't apply
P-D-C-A Plan (meet w/ compl. committ to discuss & document current position and possible steps-Do-make prelim. attempts at next steps - Check- review lessons learned - Act - decide how to incorporate what yo've learned & what you still need to do
Administrative Simplification Section of Title II (HIPAA) Triggered the regulations for standard transactions & code sets, privacy & security of health information & unique health identifiers
Federal Sentencing Guidelines Suggests offering incentives to those who follow the compliance & ethics program
Baseline Audit "snapshot" of the operations from a compliance perspective. Prelim. audit that becomes the baseline for CCO & managers to judge process in reducing/eliminating potential areas of vulnerability. OIG goal: "to facilitate identification of problem areas and
Chain of Command The hierarchy of reporting structure w/in an organization, which assumes all issues will be presented first to one's immediate supervisor
Factors that can impact the compliance budget -Training -Poor communications infrastructure -Poor data processing controls -Compensation structures that emphasize financial performance w/ no compliance consideration
Caremark International Derivative Litigation 1996 civil settlement of Caremark in which the OIG-imposed CIA precluded Caremark from providing health care in certain forms for 5 yrs. Also suggests failure of a corp director to attempt in good faith to institute compl. program may be breach of Directo
Diagnosis-Related Groups (DRGs) Classifications of diagnoses determined by the avg. cost of treating a particular condition, regardless of the
Current Procedural Terminology 2000 (CPT2000) A publication of the American Medical Association which lists and assigns codes to procedures and services performed by physicians
Culpability Score Part of U.S. Sentencing Commission guidelines for the Sentencing of Organizations, a system that adds points for aggravating factors and subtracts points for mitigating factors in the determination of fines imposed for fraud or abuse
Covered Entities 1) Health plan 2) Health care clearinghouse 3) HCP who transmits any health information in electronic form in connection with a transaction covered by [this subchapter]
Civil Monetary Penalties Law (CMPL) 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 levying of fines for such expenses
Employee Retirement Income Security Act (ERISA) A 1974 federal act that exempts self-insured health plans from state laws governing health insurance and requires health plans to provide certain information to enrollees
Equal Employment Opportunity Commission (EEOC) U.S. agency created in 1964 to end discrimination based on race, religion, sex or national origin in employment. The commission reviews and investigates charges of discrimination and, if found to be true, attempts remedy through conciliation or legal mean
False Claims Act Originally adopted in 1863 during Civil War to discourage suppliers from overcharging the federal gov't, legislation that prohibits anyone from knowingly submitting or causing to be submitted a false or fraudulent claim
Fiscal Intermediary or Fiduciary Intermediary A person or organization that, under agmt with HHS under part A of Medicare, processes claims, provides services, and issues payments on behalf of private, federal and state health benefit programs or other insurance organizations
General Services Administration (GSA) The federal agency that manages the federal government's property and record, including the construction and operations of buildings and procurement and distribution of supplies, among other functions
Health Care Clearninghouse Public or private entity that does any: 1) processes health info received from another entity in nonstandard format or containing nonstandard data; 2) receives standard transaction from other entity and processes health info into nonstandard format or non
Health Insurance Portability and Accountability Act (HIPAA) Comprehensive legislation that ensures access to health coverage for those who change jobs or are temporarily out of work. Also provides the mechanism for funding the DOJ and the FBI for Medicare fraud investigations. Protects health information
Inspector General (IG) An officer of a federal agency whose primary function is to conduct & supervise audits & investigations relating to operations & procedures over which the agency has jurisdiction
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) A not-for-profit organization that develops standards & performance measures, conducts regular on-site surveys based on those standards and measures, and awards accreditation decisions for hospitals & other health care facilities
Physicians at Teaching Hospitals An HHS/OIG nationwide review of compliance w/ rules governing physicians at teaching hospitals. Records reviewed to determine adequate physician involvement in patient care according to IL373 (Medicare rule re: attending HCP must be present when supervisi
Qui Tam Authorized by the False Claims Act (FCA) is a suit filed by an employee of an organization, a whistleblower, w/ the federal government accusing the organization of fraud and abuse. Allows employee to contact government based on original information
Balanced Budget Act of 1997 Legislation containing major reform of the Medicare and Medicaid programs esp in the areas of home health & patient transfers. It also mandated permanent exclusion from participation in federally funded health care programs of those convicted of 3 health
Anti-Kickback Law 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
Safe Harbors Explicit regulatory exceptions to otherwise legally prohibited conduct. Federal safe harbor regulations specify certain joint ventures and other arrangements concerning hospitals and/or physicians which do not violate Medicare fraud & abuse laws
Self-Referral Statute; Stark Law Refers to law prohibiting hospitals & physicians from referring services to an entity with which it/he has a financial relationship
Unbundling The illegal practice of submitting claims individually in order to maximize reimbursement for various tests/procedures which are required to be billed together. The gov't initiative investigating this issue is "Project Bad Bundle"
Upcoding Coding for a higher level than the documentation warrants
What are the 4 things a compliance program is all about? Prevention, detection, collaboration and enforcement (PDCE)
Created by: kenzieb07
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