Intro to Healthcare Flashcards
(32 cards)
Federal healthcare plans include what payers?
Federal health care plans are any plans paid through government reimbursement – Medicare, Medicaid, TRICARE, and VA programs are all administered by the Federal government.
A claim is received by a payer that subsequently requests the medical records for the date of service on the claim. What procedure should be followed by the practice?
Medical records requested from a payer may be sent to the payer based on the Treatment, Payment, and Operations provision of HIPAA. However, in doing so, the Minimum Necessary provision should be followed and only the date of service requested should be sent.
A physician billed claims to Medicare and Medicaid for procedures that were not performed on 800 patients resulting in loss of 2.6 million dollars. Is this fraud or abuse?
Fraud is defined as making false statements or making misrepresenting facts to obtain an undeserved benefit or payment from a federal health care program. This creates unnecessary costs to the federal plan. In this example billing for services that were not furnished or provided
Eight standard transactions were adopted for Electronic Data Interchange (EDI) under HIPAA. Which of the following is NOT included as a standard transaction?
The physician unique identifier number is not included in the standard transactions, although it is to be included on the claim. Payment and remittance advice, eligibility in a health plan, and coordination of benefits all contain protected health information of the patient and are included in the transaction set
HIPAA of 1996 includes a Security Rule that is established to provide what national standards for protecting and transmitting patient data. Which of the following is NOT true.
All entities are responsible for the protected health information, including the entity receiving the information. Portable electronic devices such as tablets and smart phones are to be made secure with passwords that are not shared between staff.
One of the most severe penalties that can be associated with violations of the Social Security Act is exclusion from federal health care plans. Which of the following statements is true of excluded individuals?
One of the most severe penalties associated with the Social Security Act is the ability of the Office of Inspector General (OIG) to exclude an entity or an individual from participation in any and all federal healthcare programs. This includes Medicare, Medicaid, VA programs, and Tricare. An excluded individual cannot bill for services, provide referrals or prescribe medications or order services for any beneficiary of a federally administered health plan.
The regulation of finance charges or interest applied to outstanding balances in the medical practice is under what law?
The Truth in Lending Act is also called the Consumer Credit Protection Act of 1968 that is designed to protect consumers dealing with lenders and creditors.
A physician received office space at a reduced rate for referring patients to the hospital’s out- patient physical therapy center. What law does this violate?
The anti-kickback law states that anyone who knowingly or willingly accepts or offers any items or services to induce referral is a violation of the law.
When a subpoena is received by the practice for medical records, in what circumstances may the records be released according to the HIPAA Privacy Rule?
A covered entity may disclose PHI required by a court order or administrative tribunal. A sub-poena issued by a court clerk or an attorney in a case (someone other than a judge) is not synonymous with a court order. When a subpoena is issued, it should be accompanied by a court order to release the records. Only the records specified in the order may be disclosed. When the subpoena is not accompa-nied by a court order, the covered entity must make a reasonable effort to:
- Notify the person who is the subject of the PHI about the request, giving them a chance to object to the disclosure; or to
- Seek a qualified protective order for the information from the court.
Source: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/courtorders.html
HIPAA requires that privacy practice notices be provided in several circumstances. Which if the following is NOT required?
HIPAA states that the privacy practice should be available electronically on any websites they maintain, and presented to patients as they present for care, as well as providing a notice upon request. The notice does not need to be filed in the patient’s file, however the signature showing that the patient received the notice should be filed.
HIPAA Administrative Simplification
Provisions that required sections of the law to be publicized to
explain the standards for the electronic exchange, privacy, and security of health information.
Privacy Rule
The Privacy Rule standards address how an individual’s protected health information
(PHI) may be used. PHI is “individually identifiable health information” that includes many common
identifiers, such as demographic data, name, address, birth date, and social security number. All
“covered entities” are required to follow the Privacy Rule.
Covered entities
Health plans, healthcare clearinghouses, and any healthcare provider who
transmits health information in an electronic format.
Healthcare clearinghouses
They include billing services, re-pricing companies, and community
health management information systems that process nonstandard information, received from
another entity, into a standard (or vice versa).
Business associates
Perform activities like claims processing, administration or data analysis which
involve the use or disclosure of individually identifiable health information.
MACRA
(Medicare Access and CHIP Reauthorization Act of 2015) Funding Opportunity: Measure
Development for the Quality Payment Program.
The Quality Payment Program
Quality incentive payment program for eligible physicians. Provides
two tracks in which eligible clinicians can participate:
* Merit-Based Incentive Payment System (MIPS)
* Advanced Alternative Payment Models (APMs)
Truth in Lending Act (TILA)
A federal law that was designed to protect consumers in their dealings
with lenders or creditors.
Anti-kickback Law:
Federal law that makes it a criminal offense to knowingly or willingly offer, pay,
solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable
by a federal healthcare program.
Stark Law
Prohibits physicians from “self-referral” when sending patients elsewhere for certain
services.
Qui Tam/Whistleblower provision
If an individual knows of a violation of the FCA, he or she may
bring a civil action on behalf of him or herself and on behalf of the U.S. government.
False Claims Act (FCA)
The False Claim Act protects the government from being overcharged or sold
substandard goods or services.
Abuse
An action that results in unnecessary costs to a federal healthcare program, either directly or
indirectly. The main difference between fraud and abuse is a knowingly act and intent.
Fraud
Knowingly (or should have known) making a false statement or misrepresenting facts to
obtain an undeserved benefit or payment from a federal healthcare program.
