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28 Cards in this Set
- Front
- Back
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US DEPT OF HEALTH AND HUMAN SERVICES- HHS
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PROTECTS THE HEALTH OF ALL AMERICANS. CONDUCTED BY THE OFFICE OF THE SECRETARY AND 11 AGENCIES
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CENTERS FOR DISEASE CONTROL AND PREVENTION- CDC
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MONITORING HEALTH, DETECTING AND INVESTIGATING HEALTH PROBLEMS. PREPARES FOR NEW HEALTH THREATS.
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CENTERS FOR MEDICARE AND MEDICAID SERVICES- CMS
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DEVELOPS RULES AND REGS THAT GOVERN MEDICARE AND MEDICAID. CONTRACTS OUT ADMINISTRATION OF M/CARE BENEFITS
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FOOD AND DRUG ADMINISTRATION- FDA
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APPROVES NEW DRUGS AND MEDICAL DEVICES AND REGS SAFETY IN MEDICAL AND FOOD INDUSTRIES
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NATIONAL INSTITUTE OF HEALTH- NIH
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CONDUCTS AND SUPPORTS MEDICAL RESEARCH
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OFFICE OF INSPECTOR GENERAL- OIG
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INVESTIGATES FRAUD AND ABUSE OF HHS PROGRAMS. ISSUES ADVISORY OPINIONS, ANNUAL DOCS FOR COMPLIANCE ACTIVITIES, IE THE WORK PLAN.
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FEDERAL TRADE COMMISSION- FTC
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CONSUMER PROTECTION, DIVISION OF FINANCE PRACTICES TAKES ACTION AGAINST CO'S THAT VIOLATE DEPT COLLECTION LAWS.
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SOCIAL SECURITY ADMINISTRATION- SSA
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PROTECTS ECONOMIC SAFETY OF CITIZENS; ADMINISTERS MEDICARE ELIG, (DISABILITY, END STAGE RENAL DISEASE-ESRD).
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PATIENTS' BILL OF RIGHTS
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EXPECTATIONS THAT PATIENTS, FAMILIES HAVE ABOUT HOW THEY WILL BE TREATED IN HEALTHCARE SITUATIONS; RIGHT TO PRIVACY AND SECURITY OF HEALTH INFORMATION AND RIGHT TO PARTICIPATE IN TREATMENT DECISIONS.
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RIGHT TO PRIVACY AND SECURITY OF HEALTH INFORMATION
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HIPAA-HHS ISSUES THE PRIVACY AND SECURITY RULES WHICH CREATED NATIONAL STANDARDS TO PROTECT INDIVIDUAL'S MEDICAL RECORDS AND PROTECTED HEALTH INFO
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PHI
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PROTECTED HEALTH INFORMATION-UNDER HIPAA. ANY DATA THAT COULD BE USED INDIVIDUALLY OR IN COMBO TO IDENTIFY PATIENTS WITH MEDICAL INFORMATION.
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TPO
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TREATMENT, PAYMENT OR OPERATIONS- THE CONDITIONS UNDER WHICH PHI CAN BE SHARED W/O EXPLICIT CONSENT BUT STILL MUST BE SECURE
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PHI-HOW CAN BE SHARED
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MARKETING PURPOSES-EXPLICIT CONSENT. LAW ENFORCEMENT AGENCIES-EXPLICIT CONSENT EXCEPT UNDER CORT ORDER. VENDORS-SIGN A BUSINESS ASSOCIATE AGREEMENT OBLIGATING THEM TO TREAT PHI SAME AS COVERED ENTITIES.
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NOTICE OF PRIVACY PRACTICES
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PATIENT MUST SIGN, STAFF MUST DOCUMENT REASON NOT SIGNED; MUST TRACK WHO HAS RECEIVED NOTICE AND IF IT CHANGES MUST SEND NEW COPY TO PT
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PATIENT SELF DETERMINATION ACT (1990)
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PATIENT'S RIGHT TO PARTICIPATE IN DECISIONS RE THEIR HC. ADVANCE DIRECTIVES-LIVING WILL, HC POA OR DPOA, AND DNR
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LIVING WILL
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SPECIFIES TREATMENTS A PATIENT DOES AND DOESN'T WISH TO RECEIVE
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HEALTHCARE POWER OF ATTORNEY OR DURABLE POA FOR HEALTHCARE
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DESIGNATES SOMEONE ELSE (SURROGATE, AGENT OR HC PROXY) TO MAKE DECISIONS ON PATIENT'S BEHALF IF PATIENT IS UNABLE TO DO SO.
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DO NOT RESUSCITATE (DNR) ORDER
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PATIENT DOES NOT WISH TO HAVE CPR OR SIMILAR INTERVENTIONS IN EVENT OF MEDICAL EMERGENCY
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THE PATIENT SELF DETERMINATION ACT MANDATES THAT HC PROVIDERS WHO RECEIVE FEDERAL FUNDS DO THE FOLLOWING:
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- INFORM EACH ADULT PATIENT IN WRITING OF HIS RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT AND TO CREATE AN ADVANCE DIRECTIVE
- PROVIDE EACH ADULT PT W/ WRITTEN INFO DESCRIBING THE FACILITY'S POLICIES REGARDING IMPLEMENTATION OF THESE PATIENT RIGHTS - INQUIRE AND DOC THE MED RECORDS IF PT HAS AN ADVANCE DIRECTIVE - MUST NOT DISCRIMINATING AGAINST PT BASED ON HAVING ADVANCE DIRECTIVE OR NOT. |
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FEDERAL ANTI-PATIENT DUMPING
EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT- EMTALA (1986) |
PREVENTS HOSPITALS TO REFUSE TREATING PATIENTS W/O INSURANCE OR IMPROPERLY TRANSFERING THEM TO OTHER FACILITIES
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HOW EMTALA AFFECTS HOSPITAL PRACTICES
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- PTS MUST HAVE RECEIVED A MEDICAL SCREENING EXAM BEFORE REG STAFF CAN ASK ABOUT ABILITY TO PAY
- PT MUST BE STABLE PRIOR TO TRANSFER - PHYSICIAN MUST CERTIFY THAT THE TRANSFER IS APPROPRIATE - PATIENT CAN REQUEST TRANSFER BUT NOT AT SUGGESTION OF HOSPITAL - TRANSFERRING HOSPITAL MUST SEND MEDICAL RECORDS W/ PT - RECEIVING HOSPITAL MUST AGREE TO ACCEPT PATIENT AND TRANSFERRING HOSPITAL IS RESPONSIBLE FOR PT WELL-BEING DURING TRANSFER |
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FRAUD
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AN INTERNAL DECEPTION OR MISREPRESENTATION THAT AN INDIVIDUAL KNOWS TO BE FALSE OR DOES NOT BELIEVE TO BE TRUE AND KNOWS THAT TEH DECEPTION COULD RESULT IN SOME UNAUTHORIZED BENEFIT TO HIMSELF OR SOMEONE ELSE.
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MOST FREQUENT TYPE OF FRAUD
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FROM FALSE STATEMENTS OR MISREPRESENTATIONS MADE WHICH IS MATERIAL TO ENTITLEMENT OR PAYMENT UNDER THE MEDICARE PROGRAM.
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EXAMPLES OF FRAUD
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BILLING OR SERVICES NOT RENDERED, MISREP OF SERVICES OR CODING, MISREP OF DIAGNOSIS, AND KICKBACKS.
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ABUSE
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INCIDENTS OR PRACTICES OF PROVIDERS, PHYSICIANS, OR SUPPLIERS OF SERVICES THAT ARE INCONSISTENT WITH ACCEPTED SOUND MEDICAL, BUSINESS, OR FISCAL PRACTICES RESULTING IN UNNECESSARY COSTS TO THE MEDICARE PROGRAM, IMPROPER REIMBURSEMENT FOR SERVICES THAT FAIL TO MEET PROFESSIONALLY RECOGNIZED STANDARDS OF CARE OR THAT ARE MEDICALLY UNNECESSARY.
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TYPES OF ABUSE
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MEDICARE PROGRAM IS VULNERABLE TO ABUSE IN FORM OF OVER-UTILIZATION OF SERVICES WHEN A PATIENT RECEIVES SERVICES THAT ARE NOT MEDICALLY NECESSARY OR REASONABLE.
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EXAMPLES OF ABUSE
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SERVICES NOT MEDICALLY NECESSARY, SCREENING SERVICES, VIOLATION OF ASSIGNMENT, AND WAIVING OF COINSURANCE AND/OR DEDUCTIBLES.
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HC REFORM IN 2010
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BLURRED LINES OF FRAUD AND ABUSE. INTENT IS NO LONGER A CRITERION FOR FRAUD.
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