Rules, Regulations, and Standards Flashcards
(109 cards)
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
