Rules, Regulations, and Standards Flashcards
Maintains a list of approved accreditation organizations for health care providers, as providers and suppliers who have been accredited by one of these national accrediting agencies are exempt from state surveys in determining if they are in compliance with Medicare - mandated conditions.
Centers for Medicare and Medicaid Services (CMS)
Approved Medicare accreditation organizations include:
The Joint Commission, Community health association program, and the Accreditation Commission for Health Care.
Whose role is it to update documentation requirements based on changes to regulatory or accreditation standards?
The Nursing Informatics Specialist
This committee created the standards associated with administrative medical insurance tasks.
The Accreditation Standards Committee (ASC)
This set of standards are used nationwide, helps with claims, enrollment, and determining insurance eligibility.
X12N
This council developed pharmacy standards for the U.S. Electronic claims processing under this standard was first introduced in 1992, and has gone on to make up nearly 100% of retail pharmacy claims being processed in real - time.
The National Council for Prescription Drugs Program (NCPDP)
Another NCPDP set of standards, focuses on the communication of information within and between different healthcare facilities.
HL7
Reimbursement systems
Pay for Performance (P4P) or Value - based purchasing
What is the primary objective of P4P programs?
to reward the health care providers when patients have good results.
P4P payment
related to quality versus quantity of service.
Under the Medicare Inpatient Prospective Payment System (IPPS), patient must be given…
A present - on - admission (POA) Medicare severity diagnosis - related group (MS-DRG) diagnosis.
What is the “Y” POA indicator on Medicare claims?
Medicare pays for a condition if a hospital acquired condition (HAC) is present on admission.
What is the “N” POA indicator on Medicare claims?
Medicare will not pay for condition if a HAC is present on discharge but not on admission.
What is the “U” POA indicator on Medicare claims?
Medicare will not pay for condition if a HAC is present and documentation is not adequate to determine if the condition was present on admission.
What is the “W” POA indicator on Medicare claims?
Medicare will not pay for condition if a HAC is present and if the health care provider cannot determine if the condition was present on admission.
Medicare instituted, what, for serious, preventable, hospital - acquired conditions and complications for which Medicare will not reimburse hospitals?
Do not pay list
Why does Medicare have a Do not pay list?
to control quality of care and to cut costs
How many categories are currently on the do not pay list for Medicare?
over forty
What department handles negligence and malpractice?
Risk Management
Indicates that improper care has not been provided.
Negligence
Indicates that an individual failed to provide reasonable care or to protect/ assist another, based on the standards and expertise.
Negligent conduct
Willfully providing inadequate care while disregarding the safety and security of another
Gross negligence
Involves the injured parties contributing to the harm done.
Contributory negligence
Attempts to determine what percentage of negligence is attributed to each individual involved.
Comparative Negligence
If health care providers provide patients access to them via e-mail or messaging and do not respond promptly to those messages, then they be liable for what?
Malpractice
Types of patient data misuse include:
Identity theft
Unauthorized access Privacy violations
Security breaches
Health records often contain identifying information, such as Social Security numbers, credit card numbers, birthdates, and addresses, making patients vulnerable.
Identify theft
Although EHRs and computerized documentation systems are password protected, providers sometimes share passwords or unwittingly expose their passwords when logging in, inadvertently allowing access to information about patients.
Unauthorized access
Even professionals authorized to access a patient’s record may share private information with others, such as family or friends.
Privacy violations
Data are vulnerable to security breaches of careless, inadequate security, especially when various business associates, such as billing companies, have access to private information.
Security breaches
Those who use proprietary software should require all those working with the data, including third parties, sign ____________________, to prevent information regarding the software or data from being stolen or misused.
a Nondisclosure agreement
Stealing proprietary data is most common when …
people leave an organization and is often used to benefit a new employer.
Stealing legally protected information is an act of?
Fraud
The Health insurance portability and accountability act of 1996 mandates ____________ and _______________ to ensure that health information and individual privacy are protected.
Privacy and Security
Protected information includes any information included in the medical record (electronic or paper), conversations between the physician and other health care providers, billing information, and any other form of health information. Procedures must be in place to limit access and disclosures.
Privacy Rule
Any electronic health information must be secure and protected against threats, hazards, or nonpermitted disclosures, in compliance with established standards.
Security Rule
Limiting access to those authorized, use of unique identifiers for each user, automatic logoff, encryption and decryption of protected health care information, authentication that health care data have not been altered or destroyed, monitoring of logins and security of transmission.
Security Requirements
This must include a unique identifier, procedures to access the system in emergencies, time out, and encryption/ decryption
Access controls
The two major factors for security of patient information include:
Information should be transmitted accurately and quickly.
Clinical and non - clinical systems should be fully integrated.
Requested information should be supplied within _______________ of the request.
24 hours
Passed in 1996 to protect patient privacy rights
Health Insurance Portability and Accountability Act (HIPAA)
Compliance dates: Electronic transactions and code sets are to be identified.
October 16, 2002
Compliance dates: Privacy standards are to be set.
April 14, 2003
